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SAN JOAQUIN Cr V'I'Y ENVIRONMLN'I'AL HLAL'I'H ' VARTMENI' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,0e Xt-CG t,1 R-c!5 r U i <br /> OWNER/OPERATOR <br /> -Y / C O U I� 1 CHECK if BILLING A0ORE550 <br /> FAcaRY NAME r/t/( YT — <br /> 7`- O { Y O C G u, 41 <br /> SITEADDRESStG0 E l/ �h AVc `757376 <br /> -11 <br /> Street Nu %2A�Y C/}mber erection Ir el Name CII Zip Code <br /> HOME Or MAILING ADDRESS (it/Different from Site Address) <br /> 357 Sheet Number Street Name <br /> CRY STAT–4 ZIP <br /> PHONE#1 EXT. APN N LAND/USE APPLICATION# <br /> (079) Bao - FG ll <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> c a 3s- 6 /26 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUgaTOR <br /> ,T / O U -Atdy CHECK If BILLING ADDRESS <br /> •/- PHONE# O Em <br /> BkfftNESS NAME /OS o 0_3 RC's l4'UYa i1 / Oq 3O - l� �. <br /> .-NOME or MAILING ADDRESS FAX If <br /> -) s— E-'llcY SAH y V c ) <br /> CITY TRId C, SJATE ZIP 5-3 -7 /' <br /> BILLING ACKNOWLEDGEMENT, I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-IF-ALTR DEPARTMENT hourly charges associated with this projector <br /> 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 FEDERA laws. <br /> APPLICANT'S SIGNATURE: 0116 .o d DATE: 61- ZD - O <br /> PROPLUTY/BUSINESS OWNER[] OPISRATOR/MANAGER. ❑ OTHER AUTIIORPLED AGENT❑ <br /> if Al'PLJCANT is not the BILLING PARTY.proof of authorization to sign U required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environ <br /> �,m1ental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a \at the same time it is <br /> provided to me or my representative. E <br /> TYPE OF SERVICE REQUESTED: P)oe-1Q FIEG <br /> COMMENTS: <br /> JANE16 <br /> r <br /> PFgMtiEH�P\N <br /> In <br /> APPROVED BY: '1 +EmmPLOYEE#: <br /> PLOYEE#: /,�(� DATE: '_ g-03 <br /> ASSIGNED TO: Z 33 6 ` DATE: t� <br /> Date Service Completed (it already completed): SERVICECODE: PIE: ��QZ <br /> Fee Amount: I gq0o Amount Paid r. Payment Dale <br /> Payment Type Invoice If Check# Received By: <br /> EHD 4"1-025 - SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />