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08/09/2004 15: 30 4b4idl:�b LNVIKUNMLN1AL HLALIH rant nl <br /> SAN JOAQUIN )LINTY ENVIRONMENTAL HEALTF 7,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &ASof-i"L 1D hr'6xl5 t►.IG— FAc(L I;y p, 0 C)o v h <br /> OWNER IOPERATOR 'r if El ' DDRESS❑ <br /> 13P W E5 r 00A.5 ?P-OD UO-M L- �c' <br /> FACILn NAME r41��(7 (DOZD SEP +® 20 <br /> SITE ADDRESS r '71 ✓^. V 05 F M l TEM }J' }d E uq 55 3�_ <br /> Street Number I Dlreetlon Stmet Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Streak Number Streqt Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> Em• APN# LAND USE APPUCATION# <br /> ( ) <br /> PHONE#2 EXT. [B�IIISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �I yF_�5 CHECK if BILLING ADDRESS❑ <br /> PHONE# ExT. <br /> BUSINESS NAME i AI L/J�iIZD�JIL1El�t7�L 5Y5rEMS �7i 5& 7-(0`�� <br /> HOME or MAILING ADDRESS FAX# <br /> tilEV1r-l.._E ( '714) 1.Y5-UOD/Io <br /> CnY , STATE T ZIP q2 e&S— <br /> i1 /tel C-C— C <br /> BILLING AC10WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/Or project Specific ENVIRONMENTAL HEALTT-I DRPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FF.DERAL laws. <br /> APPLICANT'S SIGNATURE: 2� �Q� DATF: <br /> PROPERTY/BUSINESS OWNER OPERATO /MANAGER ❑ OTHER AirmORIZED AGENT ZU• CODED ' <br /> If APPL1CANV is'not the 13ILLTNG PAS proof of authoriz�n to sign is required Tff(�f"A� <br /> AUTHORIZATION TO LEASE I WORMATION: When applicable, I, the owner or operator of the pra `ry% at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asse nt <br /> t <br /> information to the SAN JOAQUIN COUNTY F,NVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and a t��saln�� II <br /> COON. <br /> provided to me Or my representative. <br /> EAv VIRO,.A T <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: R L r,LA C E p 9'7 JzEb '-AC-V-r--T F X l v' 1-b VAYOV�e SS <br /> D�i[=CTD,_ , At-50 1Z�PLAC&b L 11ZE >=C>p LI V--E 1 �9 NN�l�fF2 YEED <br /> EMPLOYEE#: ���1) DATE: (—/(�� <br /> ACCEPTED BY: © A��� _ <br /> I EMPLOYEE#: � DATE: q- I C) p <br /> ASSIGNED TO: '. 1I I I+ =� <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: l PIE. p?3 0 g <br /> Fee Amount: <br /> Amount Paid $g?9, C 0 Payment Date 4 0 1)Y <br /> Payment Type <br /> Invoice# Check# Received By: <br /> �O S <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br />