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\ SAN JOAQUIN COUNTY ENVIltONIVILNTAI, HEALTH DLPAItTIVILNT SERVICE REQUEST Type of Business or Property FACILITY IDR SERVICE REQUEST 4 / E �. ti'�� tk' OWNER/ OPERATOR - /^� ((,�pp - -- '" �[jhILJI"� `t IW��,t rw� > --/ CHECKII BILLING ADDRESS FACILITY NAME SITE ADDRESS -_ K-I t-kG DOS+ FT C>A i LpD I Street Number Direction rStreet Name city 9` f G tic HOME Or MAILING ADDRESS (If Different from Site Address) �C�tJCaDO �COP.b Street Nvet mbcr w c' I 1 No C CITY Ln�( - STATE ZIP 9s Z4 PHONE R1 EXT. APN# n56-— I-IG- It LAND USE APPLICATION11 ( ) y— /l- h55— 15n—L7 7 (1,,, -1 PHONE#2 EXT. BOS DISTRICT LOCATION CGDE ( ) CONTRACTOR / SERVICE REQUESTOR REOUESTOR CHECK If BILLING A00RESS0 BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX R CITY STATE zip C BILLING ACKNOWLEDGEMENT: I, the undersigned properly or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL LIEAI.TI I 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 1 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 laws. APPLICANT'S SIGNATURE: �/ �4_l �y C� o� DATE: NZ I1qq�I PHOPE,RTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ Onirn AIIruoluziD AGrNT ILY CIY1� - If APPLICANT is riot the BILLING PANTY.proof ofauthorization to sign iS required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the properly located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment .. information to (lie 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. J TYPE OF SERVICE REQUESTED: I A Li l'1 COMMENTS: t e/rte RECEIVED - J &J�o�.�, � / FEB 1 3 2003 ,�y�I �W'�C/f7rA.,Q p SAN JOAC OUIN OUNN O _ _(O/ PUBLIC HEALTH COONS -`s +•��-�-^ pWpONMEN74 HEALTH DMSION APPROVED DY: y EMPLOYEE#: DATE: 4L2//3/e3 ASSIGNEDTO: EMPLOYEE#: DATE: Date Service Completed (If already completed): SERVICE CODE: PIE :/��"G Fee Amount: �'� Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 40-01.025 SERVICE REQUEST FORM REVISED 6-5.02