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SAN JOAQUIN �)UN'1'Y ENVI1WNIVILN'1'A1, HLeAL'1' ')I1`l'AW1'MLN'1' <br /> SERVICE REQUEST <br /> Type of Usiness or Property FACILITY ID# SERVICE RE UEST I <br /> C <br /> A2 l 6U 1_T C A1_ 0 Dset DO/9?S <br /> OWNER/OPERATOR <br /> C 14 /I 0 d T49 j./1� J-ro ` CHECK It BILLING ADDRESS <br /> FACILITY NAME ,C G �`r CJ /4'1,4 1 J <br /> SITE ADDRESS / ' <br /> / Street Number Direction Street Name Clt ZiCode <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c <br /> 5 — PA p �%�� --17G '—d/ r'�+ —�� 3t:�vr3z (IP7- <br /> PHONE#2 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / ' „ � C14ECKifBILLING ADDRESS <br /> � <br /> BUSINESS NAME C 7_1i1fPHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# _ <br /> 0 Box 5 -- ( ) <br /> CITY —Fv CK <br /> STATE </1 ZIP C S I <br /> I31I,1ING ACKNOWT,EDGis'MIsNT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-ICALTii DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or Illy 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 wish all SAN JOAQOIN <br /> COUNTY Ordinance Codes,Standards, A/ e and F• �to laws. <br /> APPLICANT'S SIGNA'I'URL': DATL: �S 03 <br /> PROPEAVI'V/IIUSINLSS(OWNER ElOPERATOR/MANAGER C10-rnGit AtrriioRizi:D AGENT ILS <br /> if APPUCAN't'is Not the 1311-1_ING PARTY,pr(-_ -1 lah'.'rization to sign is required/\ Title <br /> AUTi-10RIZA110N TO RBLEASIs INFOitMATION: 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HCALTH 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: Re V/EW <br /> COMMENTS: GJ �G j <br /> J f� <br /> -RECEIVED <br /> z,n o s o AUG 2 5 ZOO ��'r.�,� ;44 <br /> 1 SAN JOAQUIN COUNTY <br /> d j,S Y.G, (,�cr v PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED DY: �- l EMPLOYEE#: DATE: <br /> ASSIGNED TO: /1— EMPLOYEE#: �/ DATE: <br /> Date Service Complete (if already comp ed): SERVICE CODE: P/E; <br /> Fee Amount:' Amount Paid Payment Date '? a5 3 <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 40-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />