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SAN JOAQUIN UN'1'Y LNV1ltONMLN'I'AL HL:AL'1" 'L1'AR'1'IV1LN'1' ` 7— SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 6l4S 5174-T70/Q F-"0 0 74& y. S t2 00 3 7 qrSl- OWNER/OPERATOR 6P LJE-5T 00651 0 6 R O^ I f 01� ' L—� CHECK If BILLING ADDRESS CI FACILITY NAME �c � i_ � � � �,J(/` SITE ADDRESS /� Q Q J 5 ((J m R i/� �5 j � 19-53 3 7 Street Number Olr¢cllon Street Name Clt ZipCode HOME or MAILING ADDRESS (If Different from Site Address) Sheet Number Slreel Name CITY STATE ZIP PHONE 111 EXT. APN# LAND USE APPLICATION# (A2,3) 82-5 r,-7S-j PHDNE#2 EXT. DOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR -T/4- ` T- e"7/ V - G V G J 7Z-7" L0 r-1 5 6/400j,() CHECK If BILLING ADDRESS BUSINESS NAME ! , r`�-' PHONE# EXT. -t-p - 6TF--WS (C16 ) - /ORO HOME Or MAILING ADDRESS FAX# 32Ss3 Lu yu AIG DK ' (71&) 85-fj.,— 10 1 CITY Piq- I/146 061<1_00 V d STATE /JYl ZIP '7C"7LQ, BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL I-IEALTti DEPARTMCNT hourly charges associated with this projector activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: lJ p,�i�p DATE.: /�j PRApERTV/BusiNms OWNER OPERATOR/MANAGER ❑ OTiiER AUflIORIZEO AGENT PP (" Q"-t- m� If APPLICANT is not the BILUNG PAitTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator�I� T�located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or site assessment information to the SAN JOAQUIN COUNTY ENVIRONMCNTAL HEALTH DEPARTMENT as soon as it is available and at 111G, me lime it is provided to me or my representative. TYPE OF SERVICE REQUESTED: SqN jOgOUI�N�pCOUNTY ICES COMMENTS: ��v� �t�`7J E7�LI Ci��T I DR610 7V6E �9 z/66 / Dl< Dpnli u C-7 L4 00,5- tiio� c.��, (y) r W6RY 13k5-,EAK19W5, C 3� S-4- Vit TU PC / v S+ L7l2c>p Zt tg� 6 APPROVED BY: j �9 EMPLOYEE#: y DATE: 02--/t?_O3 ASSIGNED TO: vCN r& EMPLOYEE#: 03 ) 7 DATE: Date Service Completed (it already completed): SERVICE CODE: �9 g P/E: 42 3 6 Fee Amount: Amount Paid a(�7 Payment Dale e2_11—t)3 Payment Type t/ Invoice# Check# 0/ 7-- Received By: EHD 40.01-025 SERVICE REQUEST FORM REVISED 6.5-02