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SAN JOAQUI—`:OUNTY ENVIRQNME�NTAL HEALr,%DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1150# SERVICE REQUEST# <br /> 1eoe 33343e> <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS. <br /> FACILITY NAME <br /> S/IT,E ADDRE/S'S `Af ,C I ' ` J P—Te s <br /> 1lp 7�JC� Street Number Direction Street Name city Zi Code <br /> HOME Or MAILING ADDRESS (if <br /> (ifDifferent from Site Address) <br /> J / <br /> r - u Lit, 2-G l b Street Number Slreel Name <br /> CITYSTATE zip <br /> `(out-cT"lIL'L.0 CA <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ('707) Ct44 27 -0 btu - 1430 - 35 <br /> PHONE#2 ExT, C.0 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE <br /> IUP REQUESTOR <br /> RECUES OR <br /> CHECK if BILLING ADDRESS�wl <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> HOME Or MAILING ADDRESSFAx# <br /> ✓ 1 � l r i2L�l ��- ( I b <br /> CITY �� C-A LiA— STATE ZIP S 3 <br /> .BILLING ACKNOWLEDGEMENT: 1, 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 or <br /> activity will be billed to me or my business as identified on thi orm. <br /> I also certify that I have prepare his a Lica 'o <br /> - n and that a ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN'T'Y OYlindnce Codes,SI«n mrls,S ,and FGDE 1, WS. <br /> APPLICANT'S SIGNATURE: G `— DATE: ��/C) <br /> PHorENTY/BHsiNEss OWNER❑ OPERATOR/MANAGER ❑ 0THENAUTnOIUZEDAGtNTL0 "qz�' <br /> If APPLICANT iS n0t the BILLING PARTY /woof Of authorization to Sign is required Tide <br /> AUTHORIZATION TO RF,LEASF, 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 sante time it is <br /> provided to me m my representative. �d <br /> TYPE OF SERVICE REQUESTED: 501 L ,,JU 17— 'vJ(i/LF+T� �A cvde 5, <br /> COMMENTS: Y/� <br /> o� 412o <br /> �O C SP1fBLME oa`HE RH HEv 510N <br /> APPROVED BY: EMPLOYEE#: 2 2b'Z DATE: �y%0 03 <br /> ASSIGNED TO; �(.T�S' <br /> EMPLOYEE#: %�(� DATE: n /�%Q.��3 <br /> Date Service Completed (if already completed): SERVICE CODE: Jr25 PIE: (HOZ <br /> Fee Amount: 75� Amount Paid %f 50D Payment Date �)t,l.L <br /> Payment Type Invoice# Check# - Received By: <br /> SERVICE REQUEST P <br /> _ EHD 48-01-025 <br /> REVISED 6-5-02 <br />