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~ SAN JOAQLOUNTY ENVIRONMENTAL HEAEPARTMENT SERVICE RE QUEST LIV Type of Business or Property Ilk,e- /1— Al 1 FACILITY ID # / SERVICE REQUEST # /VaTC.-,tet/ k eC(7✓ tfy 1% d- BUSINESS NAME 't `t 03 " PHONE # 00333 L/h � � � —C C/ Ae% % c1wM l/y7� L1'2 OWNER / OPERATOR ( 9'16) 3 CITY STATE C- 4 CHECK If BILLING ADDRESS FACILITY NAME Cllsvt"r TlC! SITE ADDRESS /-„� 3 V ? � ENVIRONMENTAL APPROVED BY: -treet Number Direction Street Name ASSIGNED TO:/ C Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) EMPLOYEE #: G DATE: Date Service Lornpleted Street Number (if already completed): Street Name CITY 5 % STATE ZIP PHONE #1 EXT. ( ) APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) Payment Type DISTRICT r LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Ilk,e- /1— Al 1 �/,ev` S / `j / COMMENTS: S` CHECK If BILLING ADDRESS BUSINESS NAME 't `t 03 " PHONE # EXT. HOME or AILING ADDRESS % c1wM FAX # gel O kr3 ( 9'16) 3 CITY STATE C- 4 ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL I-IEALTii 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 0/'dititil1L'e Codes, StarrdardS, STATE and FEDERAL laws. �/ APPLICANT'S SIGNATURE: C -11k � �� DATE: / / d� PROPFIITY / BUSINESS OWNER ❑ OPERATOR / MANACER OTHER AUTIIOIIIZFD AGENT /—C r c ,� if ADPL/CANT is not the BILLING PARTY, proof of authorilatioit to sigh is required Title AUTI-I0R1ZATI0N TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geoteclutical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPAR'rMENT as soon as it is available and at the same time it is provided to me or my representative. AGN t TYPE OF SERVICE REQUESTED: Ilk,e- /1— Al 1 �/,ev` S / `j cE1VE�' COMMENTS: S` b3 -- I 2-1t13 J 1` p ¢v\Cvv-eAL FkY04 �--"vP* _ j 1& rM*� 't `t 03 " % c1wM ,� p,PR SPU6LIOH�A H SRV CES HEA!Sµ p',vIS10r ENVIRONMENTAL APPROVED BY: EMPLOYEE #: C , DATE: Ci ASSIGNED TO:/ ' V EMPLOYEE #: G DATE: Date Service Lornpleted (if already completed): SERVICE CODE: 5 % P / E: Fee Amount: C75 Amount Paid '1 Payment Date N, Payment Type Invoice # Check # �-7 L Received By: EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM