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JAN JUAVUEN I.VUN 1 Y EN VIKONMEN'IAL nEAL'I'H UEPAR'I-MEN'I <br /> SERVICE REQUEST <br /> D# SERVICE REQUEST <br /> Type of Business or Property FACILITY I # <br /> c�side���ia I o 3 �/j o l <br /> OWNER/OPF,RATOR <br /> CHECK if BILLING ADDRESS <br /> S L Lu <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ,3 /lonse"M Road Tracy 95374 <br /> 23463 Streel Number Direction rj tree/N`aQme C Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) //�/�y 1A� <br /> 38 6 St eet Number v`/ Street Name <br /> CINE II,&; T! CA ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION If <br /> (J 61 ) 7N- 3--2 - - 9 <br /> PHONE 02 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESSEJ <br /> BUSINESS NAME (/T PHONE If E' . <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <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 HEALTH DEPARTMENT hourly charges associated with this project or <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 apd that the wo to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT&and E^DERAL laws( <br /> APPLICANT'SSIGNATURE: P(4A-^ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required TW e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> infomtation 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: ,Su 4FV4 cz SUSS-Q sCF-r4c t= CO.aT AV <br /> COMMENTS: 1-3t� RECEI�/ED <br /> STV J' / !� AUG 5 2004 <br /> 3 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: L L L)G(e� EMPLOYEE#: D 3 Zi DATE: el T L <br /> ASSIGNED TO: 9 US S EMPLOYEE#: �C f S'� DATE: g�jS(p L/ <br /> Date Service Completed (if already completed): SERVICE CODE: 3t.5 P1 E: ,� <br /> Fee Amount: 1`x.00 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 />