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FROM :TLM PETRO LABOR FORCE FAX NO. :5629238138 11. 28 2004 01:OOPM P3i7 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC>`ReQUEST# <br /> Cgas <br /> OWNER/OPERATOR �y� <br /> /r�? Wei.+ COAs� Prt. vc. { <br /> +5 , L.LC-C H CHECK BILUNO ADDRESS O <br /> FACILITY NAME A rc� 63 <br /> 313 r GN <br /> SREADDRESS loo —TM45th J4 MQh�•Q,Oa gS33� <br /> Street Number roc ✓ n t CI ZipCod* <br /> HOME or MAI4Qm ADDRESS (If Different from Site Address) <br /> 15P Art* Street'TNumber T� Name _ <br /> CITY ^ STATE ZIP <br /> `q <br /> L.q ?01I -A 80623 <br /> PHONE#1 ExT APN# LANu USE APPLIGATION i# <br /> (*14 ) 6-t <br /> PHONE#2 EXT. BOS DiSTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -}'LwA R� 9 _[Or, Fby-Ge, IN� CHECK If BILLING ADDRESS <br /> Bl1SIN s NAME �l.Gio 1 PHONE# EXT. <br /> T/T'1 w, -L <br /> Hofnl:or MAII.INe ADDRESSFAX1 <br /> gibs $� s ' ( � ) q23- 13s' <br /> CITY W h C STATE ZIP M0-4 L,1 <br /> BILLING ACKNOWLEDGEMENT: III, 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandardv,STATE and FEDERAL laws. y <br /> APPLICANT'S SIGNATURE: DATF! Zd 0 1 _ <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> ,&UTHORIZATI ON 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VS-T IZ-etni.6 - D <br /> 1 <br /> COMMENTS: <br /> JuL2g2004 <br /> SAN JOAQUIN COUNN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPOOvenoy: i .+�� �fAPLDYEE : �� DATE "./ s� D <br /> A:ssidNeo Tb: ! �� EMPLOYEE At: I DATE, I 4 D <br /> Date Service Completed (If alrerrdy complatod): SERVICE COOS: � � P! 2 30 D <br /> Fee AM60t: ''C.� () Amnufa .Paid 'L C ,ob payment bate .. <br /> Pay tf►rL<ttt Type invoice.# Check# ( y Received 13y: f <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />