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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST y To FACILITY ID # SERVICE REQUEST # S+toP- Go CITY ItA I LP 'TAS STATE /' ZIP S 2 C M TR NY V NH / 1` 1 I ENAME C, fAO P"''f %t N CHECK 1i BILLING ADDRESS� TA R j G A �J SITE ADDRESS (A 7' 6 \Lt OSr 7 �V j Street Number MITA A v & M AN TC -CA 55�j � Direction HOME or MAILING ADDRESS (If Different from Site Address) Street Name CI ZI Code ! D Y dJ WA MIL -TION AV& CITY M (L I IAS Site NumOer Street Name STATE CA ZIP }� � 50 �5 PHONE#t IEn. ( p) %5_ / Q 6 4O�j O.0 APN# ,2�0 - LAND USE APPLICATION# t � C -6 5- PHONE #2 EXT. ASSIGNED TO: � BO$ DISTRICT LOCATION CODE UO N'MACTOR /(SERVICE REQUESTOR t �/}' / REQUESTOR /� r,, J..{ (,, CTU HOA I �t 1 ` I v CTU ] c Iv CHECK If BILLING ADDRESS Ily BUSINESS NAME NCT `Y60 t)E-S I&ris, U l PE# EXT. HON HOME Or MAILING ADDRESS I o 3 8 i-► A M I LTO N /o- if C Fac# CITY ItA I LP 'TAS STATE /' ZIP S 2 C D1LLX1\U AXdVNV WLGIIGSM'I'.IN'1: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 1 have prepared this application a e work t e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE F - AL laws. APPLICANT'S SIGNATURE: DATE: r S ZI PROPERT'/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZEDAGENT AA /fAPPL/CANT is not the B/LLLNG PARTY proof df authorization t0 sign is requited Title AUTHORIZATION 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, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provided to me or my representative. p TYPE OF SERVICE REQUESTED: N,ew A, ' Y COMMENTS: Te C.•'(Y6--1 LZ (GL N S AtlG 18 Sq N✓o ?�?1 GT IRON /N C0 H�Epg' R ACCEPTED BY: Cu-V'rrL."C..S C p EMPLOYEE DATE; ASSIGNED TO: � EMPLOYEE M DATE; 17 Date Service Completed (If already completed): SERVICECODE: Z3 PIE: Fee Amount:�Amount P ' � -6 Payment Date 8 Payment Type j,5 a, Invoice # Check # Z 7q12 Received By: EHD 48-02-025 C-,v� 12-13 7 R (Z 3 SR FORMGolden Rod REVISED 11/17/2003 ( )