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')AIV J UAQ U1A ' ''UiV'1 Y 1L i\V 11ZUNiV1�N'1'AL 1tiEAL'1'H 1zPAlt"1'iti1P N'i' �-- SERVICE REQUEST --- Type of Business or Property FACILITY ID# SERVICE REQUEST# 5400 30 OWNER/OPERATOR � 'LL C- CHECK if BILLING ADDRESS❑w� c2 tis- 3zsS c J. ll-eG Ll-".(- FACILITY NAME SITE ADDRESS [5 3 N r htnn R d L� 4 I Ty� 2-Y z, Street Number Direction Street Name Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) � (N I C 1^ LQ Street Number Street Name CITY STATE C ZIP , - PHONE#1 EXT. AP # 3 �.`r ` LAND USE APPLICATION# (Z-J ) Li 73 6, ' ;c CQ " e 1 © R 1 PHONE#2 EXT• BOS DISTRICT LOCATION CODE Lf 7 3 671 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR / IZ&vi U f 1 , 1&;l — ,��Mtn A �, ��(3��L CHECK if BILLING ADDRES BUSINESS NAME [-t ✓C f `rC�' PHONE# EXT. z ' 1[7 3 -� HOME or MAILING ADDRESS FAX# CITY S-6,L+z,, STATE �T/I ZIP G, —2 t � BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standardl,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: L .� �— DATE: PROPERTY/BUSINESS OWNER/ICt� OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: r C 44(n I h4 f'/ Q eOr't COMMENTS: gr N 02513 Orl I 0251 30G 9- r100 ) -25 1( r.'S p -2513"u � S p2513 � 54 25130 G9 p 2 513,3 s 7 AUG �m� a,�tr 0 2.S 1 ,3� 4 " RubRT SAN JOAQUIN COUNTY W-wE� PUBLIC HEAT TH. APPROVED BY:I; II� OYEE#: 'iZ Q Z DATE: ASSIGNED TO: `J EMPLOYEE#: G DATE: V Date Service Completed (if already completed): SERVICE CODE: 3 1 PIE:? V i13 Fee Amount: I 'l Amount Paid �7 Payment Date Payment Type ✓ Invoice# Check# / Z ac Received By: EHD 48-01-025 SERVICE REQ UE FORM REVISED 6-5-02 �o /