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JUN-02-2004 13:52 P.02 <br /> 2084 11:39 4640138 T ENT/IRCNMENTAL HEA PAGE 02 <br /> SAN JOAQUIN COUNTY ENVURONMENTAL HEALTH DEPART�NT <br /> SERVICE REQUEST <br /> FrypaBusiness or Property FACILITY ID 3 SERVICE REQUEST C <br /> I OPERATOR R1 1r.�{ t GLC <br /> CHECK it @ILUNG AOOnE55❑ <br /> FACIM NAME t /� A r7�p <br /> SITE ADDRESS 14o64 'W MAd1LA (ZCA0 Nt' lWl 95330 <br /> G I <br /> 8 NumPer Ireelbn 7� � ,t,� �p �,r-� <br /> HOME Or MAILING ADDRESS (it DiHerwnt fmrn Site Address) 2?20 l DO&ptAo:T, 1�L ✓`1 �7 '—q C' <br /> Sheet Nymbo Sh <br /> STATE CK <br /> ZIP U <br /> CITY 1 <br /> (ZpS�llll.E V „'� V L <br /> ,AAO USE APPUCATIO01 71 <br /> P11�) 7$2 333U r . 1127t7 " bl " tI �4 - o�oozc�f, <br /> K.T. 0OS DISTRICT LOCATION OOE <br /> PtICNER 7 ff <br /> l ) <br /> CONTRACTOR / SERVICE REQIUESTOR <br /> REQUESTOR /IL'�.�� L� ChErx l{6iLLmIG Ao(flF39® <br /> liuslNr.s NAM E ��E.V I LI.E I�VL-ST M`ovll'S f t,(.(��y �J�] v pe s <br /> HOME Or MAILING ADD RE SS 22.Zt.., P00( r A5 f7 �v >,I �) Iq V FAX <br /> II ) qg 33(e <br /> L VV ✓IMIJKV t7 STATE 4IP 5 <br /> cm (L.py'�JIL-L� ✓rte 4W <br /> ILII t rta[: sCKNOWL1rDGEMENT: I, the undersigned proporty or business Owner, operator or authorized agent of sonic, <br /> at}mowledge that all site and/or project specifie ENVIRONMENTAL.HFALTN DEPARTMENT hourly charges associated with this pmjcct Of <br /> activirywill be billed to me or my business As identified on this form. <br /> 1 also certify that 1 have prepared this appI and that the or erfonned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S E ajd\FED L laws. /_ r1 <br /> X APPLICA14T'S SIGNATURE: <br /> U DATE: <br /> ILP - 4- b� <br /> PndreRTY l BUSINESS OWNER❑ O BATOR . ANA(;ER ❑ OTRERAVTr10Rt2ED AGENT E r Fa1i+ <br /> If APPLrCAiVT 0,90E the B! proof of out rizatioe to sign it required Thte <br /> AUTHORIZATION TO RELEASE 1NFORMATL0_N:'Whca applicable, I, the owner or operator of the property located at thn <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or rnvirotvrlental/site assessment <br /> information to the SAN JOAQUIN COUNCY);1`'r1RONMENTAL HEALTK DEPARTMENT as soon as it is available and at the Same bine it c <br /> provided to me or my repro-eaetative. <br /> TYPE(M SERVICE REOU ESTED' S LA[�'1- �t-C cS S-�t LJ'`F�4t t CUti�4r'-r r Nt¢T/ PAX C)4 7 <br /> E D <br /> COyMENTS: <br /> �i K JUN 2 2004 <br /> tv� VA� SAN JOAQUIN COUNTY <br /> 3O ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> EMPLOYEES: C73y/ DATE: (' 2— G <br /> ACCEPTED Env- �LCli�t� <br /> HMPLOTEE#: /l.F S(�� DATE: �" y O <br /> ASSIGNED TO: 0- S� <br /> sERVEttccuE: CI PIE; ;2-(o.G3 <br /> Date Service Completed (r atroady completed): .3 S <br /> Fee Amount: Amount Paid Payment Date - <br /> (• GJ <br /> Payment Type <br /> Invoice# Check# Received By. <br /> TOTAL P.OF <br />