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SAN JOAQUIN COUNTY`s NVIR7NMENTAL HEALTH DEPARTMENT <br /> Type of Business or Property SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR SR 0 '045-�a(�r <br /> Gasqnar <br /> FACILITY NAME CHECK If BILLING 0 <br /> SITE ADDRESS <br /> 11230 E <br /> Street Number Directi n Jahant <br /> HOME Or MAILING ADDRESS (If Different from Site Address) a eet Na a Acampo 95220 <br /> CITY2919 coca <br /> S[reetNumber Heritage Oak Way <br /> Street Name <br /> PHONE#1 STATE ZIP <br /> ( ) ET' APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 007-380-11 unassigned <br /> BOS DISTRICT <br /> Locnrlorl Co^F <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE RE <br /> QUESTOR <br /> BUSINESS NAME ensulek CHECK if BILLINBILLIN�SS <br /> HOME or MAILING ADDRESS PHONE# Er . <br /> CITY Industria FAX III <br /> ( 1 -4 <br /> BILLING ACKNOWLED STATE CA ZIP <br /> GEMENT: 1, the undersigned <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> g property or business owner, operator or authorized agent of same, <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN ' <br /> COUNTY Ordinance(7odes,Standards, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER DATE: I Z • ' 4 - <br /> O ERATOR/M AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> f APPL/CANT is not the BILLING PAR Proof of authorization to sign is required <br /> AUTHORIZATION TO 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 /> Infortriatlon to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availab1t,atlda� <br /> provided to me or my representative. Y lY IVltt�l fame time it is <br /> TYPE OF SERVICEREQUESTED:SOII Suitability/Nitrate Loading Study Review <br /> COMMENTS: <br /> ® SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: 5 EMPLOYEE#: DATE:f / <br /> ASSIGNED TO: EMPLOYEE#: �rr=' Cl— g7lL DATE:V,y <br /> Date Service Completed (if already completed): SERVICECODE: I$2, PIE:46 6Z <br /> Fee Amount: ¢ Amount Paid tg ll! (�. C) Payment Date I�! ` L-l p S <br /> Payment Type Invoice# Check# I Received 8y: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />