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SAN JOAQw--f+ COUNTY ENVIRONMENTAL HEAmri DEPARTMENT ............ SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST q S2oo Ow RI OP TOR Or cc, �O CHECK If BILI-m ADDRESS FACILITY NAME SITEAADD-R-ESS ?--- !o l/ Street Number /Dirveclion J SlreelN�aQmJeL hl CI ZI Cotle HOME Or MAILING ADDRESS If Different from Site Address) street Number Street Name CI Y� STATS ^ ZIP PHONE#1 EXT, APN# LAND USE APPLICATION# ( a3�) `�`6 13 06_2 05 C�D7 3�J—off piq DZ-101 PHONE#2 EYT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 1 �^ ,. � LP4-k CHECK If BILLING ADDRESS 3LP BUSINESSNAME e /,j/^ ) /V u0-957,� p�)l� 3/ ql r HOME or MAILING ADDRESS /'-t� 0 (�G#�1) 36-7 —Ly7 q CITY LUC(` L/ STATECA ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTii DEPARTMENT hourly charges associated with this projector activity will be billed to nae or my burin as identified on this form. I also certify that I have prepared this is loll it that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,S ERAL laws. - 1 APPLICANT'S SIGNATURE: DATE: PR0VKRTY/BUST N FSS O WN ER❑ OPERAT /MANAGER ❑ OTI I ER AUTI IO R 17.F.D AC ENT❑ C 'h L4, CfJ OY' if APVL/CANT is not the BiLf.IN PARTY proof of authorization to sign is required Title AUTHOR17.ATION TO REI,EASF. 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTil DEPARTMENT as Soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: /7-At-f5 1 ,7'36 '=V �'>'�7� �iS ,��73 �l�itLt�! b y1a4� /+�?C wc4za�% �*/ 4 crldL7csi6 ✓1 /!s 9�✓ iii as za /ss��a ,✓Au�s TI�tT� 4 -s v�Pe�r3ny �t�fis rh o e&s Q� c .✓eEz �s1r s22;) zxse a.ra7.¢esrix/ 1�6z1j lt-p?s7•�ir+�� ri T/ =/ 'VGlv✓ly=!`TIL-fL[C2'�tee/7/�'s 'iIZ.nY 7fl6TlLfit6t!A!S Us c 157 A,7T7 k)eLss& 7 Z�fLS 't!A(b.Llf7eY�Gx�S!/YP /��'i/Y/2, G��2�✓4-! itI-G-J�2G7�4LC` APPROVED BY: EMPLOYEE#: 7c/' DATE: ASSIGNED TO: EMPLOYEE#: ©/ DATE- 9 d3 Date Service Completed (if already completed): SERVICE CODE: P I E: Z Fee Amount: 3 o Amount Paid V q 3 _ Payment Date Lr4lb 3 Payment Type L/ Invoice# Check# Lfp Received By: � EI-D 48-01.025 SERVICE REQUEST FORM REVISED 6-5-02