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SAN JOAQUIN C JN'1'Y ENVIRONMI;N'I'AL HLeAL'I'!I SPAWIWIEN'1' <br /> SERVICL REQUEST <br /> Type of Business or Property FACILITY ID I SERVICE REQUEST t <br /> VA C:A1Q i PP-0('C-1Z-F 5�UV 3 z 8Z <br /> OWNER/OPERATOR . <br /> -L/ ^ ' a _/ CHECK If BILLING ADDRESS <br /> FActuTY NAME ,�/ <br /> /dtZDF—N — 2M <br /> SITE ADDRESS /ZDF-Rf1'J6(-I A�'I� Ij Z3I <br /> Ie� SbeciNumber Dlr ctlon Street Name city zip Coot, <br /> HOME Or MAILING ADDRESS (I1 Differre/nt from Site Address) <br /> F613 V- Street Number Street Name <br /> CITY , n STATE ZIP '_ <br /> ���NC N C6�rnl (IA <br /> PHONEIIIv� EXT. APNN /'75 - / 0 - IL LAND USE APPLICATION If �O� <br /> ( ) ,j 9 -4 - ) 70 t-7! -- Wo - C/ L /bC L_ /5SGffJ YfT <br /> PHONE112 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR / CHECK 11 BILLING ADDRESS Er <br /> BUSINESS NAME PHONE I EaT. <br /> cs��y ���s�<L ;,N <br /> HOME Or MAILING ADDRESS FAX I <br /> 6' L BOX -3-714 1 ) L' Z s if3 <br /> CITYf" L/J C./� STATE �'; ^ ZIP 5 , �, J <br /> (� r` Cl/ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sane, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-IEALni DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to ntc or my business as identified on this form. <br /> I also certify that 1 have prepared this appli 'on and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FED• A S. <br /> APPLICANT'S SIGNATURE: DATE: /2- <br /> PROPERTY/BUSINESS OWNER❑ OI•ERATOR/MANAGER ❑ OT}� •R AUTIIORIzED AGENT <br /> If At9'ucAlvT is Hot the DtLLtn'G PAR 7Y proof ojautharifalion to sign LT required Title <br /> AUTHORIZATION TO RULEASC INFORMATION: When applicable, I, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> .. information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HCALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 'U)ZrACi- Ei 5UP5Z9WFA 4 i LL/'O/��/, At/'h�t AI`47-t Oru Risf'o/z' <br /> COMMENTS: /j /"✓J��OT.. / WVCIVFT`�. <br /> OEC 16 200? <br /> SAN JOAQUIN, <br /> PUBLICs y <br /> RVUIRONMFPHE-ItTH'- <br /> APPROVED DY: EMPLOYEE I: y L� DATE: <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: <br /> Dale Service Completed (if already completed): SERVICE CODE: '3( � P/E: 0 <br /> Fee Amount• ('`7 Amount Paid �Check <br /> ' Payment Dale ,r <br /> yment Type j Invoice If Received By: ( <br /> ED <br /> SERVICE REQUEST FORM / <br /> ED 65-02 1 <br />