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10129/2003 14:46 2694683433 FIFTH FLOCK PAGE 08 <br />SAN JOAQUI*UNTY ENVIRONXEN"TAL HEALTH 19ARTNIENT <br />SERVICE REQUEST <br />Type of Business or Property <br />P'ACILITY.ID # <br />SERVICE REQUEST # <br />BUSINESS NAME <br />SA GL-�� i�u mF� Came <br />P�N� <br />� <br />Bxr' <br />367 - —IbOO <br />OWNER I OPERATOR -- <br />- -- <br />tit(eCKIfBI <br />I R' <br />S CC�l1+�T'� PLi L� l t?062-1� s OP +� 1`r► < <i:1J IJ —TrL .,—, M �o (L <br />rracurryS NAME <br />STATE CA <br />NTVi=S <br />ZIP <br />SITE ADDRESS <br />HEALTH DEPARTMENT <br />aL-V Z <br />I <br />EMPLOYEE #t: <br />CSP <br />�SZ3 <br />/000 StreoNumber <br />Dim 'nn <br />StrwName <br />SERVICE UCOOE: <br />city <br />ZEDCode <br />HOME Or MAILING ADDRESS {tf Different from Site Address) <br />Date { 103/®3 <br />5traet Na <br />Serve! Name <br />CITY STATE <br />ZIP <br />PHONE61 EXT. <br />APN # <br />LAND USE -APPLICATION # <br />(??fit) 4oB- 3ro4 <br />PHONE#2 EXT. <br />I{ ) <br />Bos DISTRICT <br />Loc4TION CQDE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE(2UESTOR <br />�+ <br />CHECK it AILLPIG MDRE$S <br />BUSINESS NAME <br />SA GL-�� i�u mF� Came <br />P�N� <br />� <br />Bxr' <br />367 - —IbOO <br />Homp or MAe_I ADDRIESS <br />-'3-7U rAA6G7,Q CXV-e-L-e <br />rAx $ <br />RjQqy <br />-7 S4 -24 - <br />CITY ammook LCAT <br />STATE CA <br />Zip qS244) <br />BILLING ACKNOWLEDGEMENT, I, the undersigned property or business owner, operator or authorized. agent of same, <br />acknowledge that all site ardlorproject specific ENvrr oNmEATTALHEALTii DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified or, this Perm. <br />I also certify that I have prepared this appiicatioa and that the work to be performed will be done in accordance with all SAN JoA Qutiv <br />COUNTY Ordinance Codes, Standar �TEarid FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY I BuMNESS OWNER ❑ OP! R / MANAGER ❑ OTHF AUTHORIZED AGENT %L <br />If APPLIC,RNT is not the SILLNG P ARTi, proof of authorization to sign is required rifle <br />A-UTHORI ZATIQiL Tfl_RELEASE_INFQPAJATI : When applicable, I, the owner or operator of the property located at Lre <br />above site address, hereby authorize the release of any and all :results, geotechnical data and/or emironrnentaYsite as9essmant <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Sante time it is <br />provided to me or my representative_ PAYMENT <br />TYPE OF SERVICE REQUESTED:_ <br />RECEIVED <br />COMMENTS: P Zj v i -'Sp o a i— / <br />�,/� <br />NOV 32003 <br />SAN JOAQUIN COUNTI" <br />ENVIRONMENTAL <br />ZIP <br />HEALTH DEPARTMENT <br />APPRQVED 3Y' <br />EMPLOYEE #t: <br />DATE, <br />1 A ssIGNED TO' • <br />EMPLOYEE #_ <br />OAr%:C e j <br />Date Service Completed (if alroady com pleted): <br />SERVICE UCOOE: <br />Pi E: Z Ue- <br />Fee Amount- 3kRy`ug3,rca�i4oc,R <br />Amount Paid $ Zr14,nC� �].Payment <br />Date { 103/®3 <br />Payment Type eyt,u< <br />Invoice # <br />Check # r7&7 j3 <br />Received i3y: <br />EMID 48-01-025 SERVICE REQUEST FORM <br />RSVISED 0-5-02 <br />a <br />- -111 1.,". — "­"" , - �.. , ,, -,- '-1- " ' — - f <br />