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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAI.,TH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PAIrzy l-lzy �'CD-735G5 <br /> OWNER/ PERATOR <br /> 5t t LLC CHECK If BILLING ADDRESS <br /> 'R 4 VA <br /> FACILITY NAME <br /> SITE ADDRESS 0 G A P—T-H g- R D �SCRLO/� gs3a o <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (d- ) 5-35 o.;?-7 6770- o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR DoN <br /> 5 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C-H S(4 L D D <br /> HOME or MAILING ADDRESS FAX# <br /> PO . 6 o ( ) <br /> CITY n STATE ZIP 5 f <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.HEAL.TII DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this ang Itation anc t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance('od'es,Standards T; TE and D ' t,laws. <br /> APPt.ICANT'S SIGNATURE: D:a'rL:: 2 3law—* <br /> PROPERTY/BUSINESS OWNER❑ OPERATO i MANAGER ❑4orization <br /> OTHER Al THORIZED AGENT 0 <br /> PPI.ICAA'7'is not the BILLING PARTY proof oJ' to sign is required Title <br /> AUT11ORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property 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 HEALTH DEPARTMEN"I'as soon as it is available and at the same time it is <br /> provided to me or my representative. c <br /> TYPE OF SERVICE REQUESTED: S L S �L <br /> COMMENTS: IVES <br /> S�APR Z 3 ?0?1 <br /> H� iRDNME O�Nry <br /> H�FpgRNTAL <br /> ACCEPTED BY: EMPLOYEE#: f a DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 Z 3 P I E:Z 6rjZ <br /> Fee Amount: Amount Pai 6b Payment Date <br /> Payment Type Invoice# Check# l Receiv By: CAL <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />