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SAN JOAQ*OUNTY ENVIRONMENTAL HEALTI•EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S feJA Gas SWF� Qar, 3�38 X6104(v!�9�3 <br /> OWNER/OPERATOR - <br /> ZO W• L/r�a1Jr IZ.(, vwr�1 VLC- CHECK If BILLING ADDRESS <br /> FACILITY NAME /' c^I JS'k� /`�Sy c�•lr f •I--/�I �• L it <br /> SRE ADDRESS m10� r" J tr-p•L/�1.077N1V7� J Tv G.'IC..�pyl 1 ��-06` <br /> 6 Street Number Direction Street Name CI Zip Code <br /> NOME Or MAILING ADDRESS (If Different from Site Address) ( <br /> Scra GN 'Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (702-' (D34 1(os— 04-o — 0"7 <br /> PHONE#2 E% . BOS DISTRICT LOCATION CODE <br /> 4aw Ib45b) 7ya _ col <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Td N 7 S( tvG ki CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAME /�' -��}-- PHONE# Ext. <br /> CS® f f^ t) n )wo,.4r t +mom 702- 287---0 <br /> HOME Or MAILING ADDRESSFAx# <br /> W. S w �� [' I' (7a24 6 C14 --- 23 <br /> CITYI �. _ /� N,r e y. STATE Nq ZIP 85 (- <br /> BILLING <br /> rf, (ZBILLING ACKNO EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: --T" L� , DATE: 6 b l( q 13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT is not the BtLL7NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 DEPARTMENT as soon as it is available and.alrSj7y,5amP�(j`e it is <br /> provided to me or my representative. PAWW <br /> fVl Cry ( <br /> TYPE OF SERVICE REQUESTED: I"CQir� (�L .�1/jV/ WU/Vtn lM.tt.W� <br /> REeervtu <br /> COMMENTS: f APR ,. <br /> v •l�"- Lf C SAN JOAQUIN COUNTY <br /> JJJ ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: n' EMPLOYEE#: DATE: "t /G / <br /> ASSIGNED TO: I / EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: LL Z3 P 1 E: <br /> Fee Amount: + ?, 7 5 Amount Paid -";_,�,.,� Payment Date <br /> Payment Type Invoice# Check# Received By. /,' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />