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JAN J UA1j U 1N l.0 UN'1 Y LSN V IRON MENIAL nEAL I H IJI�VAX I tV1EN f SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# C5L Spl 0330—]Z OWNER I OPlR1illiCR CHECK If BILLING ADDRES tC�t MC twt FACILITY NAME {- I SITE /GEyS67 C" �r{ nR ✓t f�C� /-tLQ'hl a 9S2Z0 / Street Number Direction (met Name i Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) S QM Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# - (3o-7 - ISE) -o ' CIA b tJo PHONE#2 EXT. BOS DISTRICT LOCATION CODE t 1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR F I rQY'N e5"� �� Sw.t �k CHECK If BILLING ADDRESS BUSINESS NAMEE, G PHONE# r I I � EXT. CLV Ll �I HOME or MAILINGADDRESS FAX# ZZ w . Duk CITY STATE ZIP C- 9S.a vfl BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL la APPLICANT'S SIGNATURE: I DATE� . 3—/:3 —O 3 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORizEDAGEN�,CIy` G/✓/L js�,vGt2 IfAPPL/CANT is not the BILLING PARTY proof of attt/toriZation to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environnTental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 1 1 L TYPE OF SERVICE REQUESTED: �C✓1 t°.a,J So s ,SU LTL t t 7 -ry PAYMENT COMMENTS: eZ _ F t++e r S v b D 2. D D 4.g'4- %y�� MAR 13 2003 SAN JOAQUIN COUtiTY �"t'zs"rl .1i4�Cr a�.a PUBLIC HEALTH SERVICE,: ENVIRONMENTAL HEALTH DIV'SIO, APPROVED BY: ,�. 0 EMP OYEE#: 2L g DATE: 7 ASSIGNED TO: Leti va-1 a 1 EMPLOYEE#: S3 Cc DATE: ? —(3 - Z Date Service Completed (if already completed): SERVICE CODE: 5ZZ PIE: Z� v Fee Amount: "D Amount Paid Payment Date Payment Type Invoice# Check# /�',3 �; �. . Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 J