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VI%,k[U7IN vvUIN I 1 AS IN YIIWOHVILlV IAL AAL'Al r �l LLl'r11C1'IVIL(VY SERVICE REQUEST �! 1 Type of Business or Property. . ;Y,:;EACILITY ID#` ',' `mai : SERVICE REQUEST'q'i,16r&,i OWNER OPERATOR CHECK If BRLINO ADDRESs[3 FACILITY NAME 1 SITE ADDRESS y t 2 � '. AAAA . .. . . -•�. rSkeet Number Oirection _- HOME Or MAILING ADDRESS (If Different from Site Address) - - ' .•,,` � SIrest Number ftale .. I, CITY _ STATE L, , _ ZIP PHONE 11 APN 0.. LAN U APPLICATION# C? �;-l- 0/ oz-��S PHONE#2 ' En. 0OSDISTRICT0% • s ,Loc/iY10N` - ( r t • CONTRACTOR/ SERVICE REQUESTOR Y REQUESTOR � G CHECK If BiLueo ADDRESS❑ l7 BUSINESS NAMEPHONE# E". ('.•_ K� C 6r r 2tJ 7-y-f HOME Or MAILING ADDRESS FAx# 7 90 ;2,25y CITY STATE a Zip )3ILLiNG 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 project or`.., activity will be billed to me or my business as identified on this form I also certify that I have prepared [his application and that the work to be performed will be done in accordance with all SAN JOAQUIN , .�; COUNTY Ordinance Codes,Standards and FEDERAL lawns. APPLICANT'S SIGNATURE: it p��Y LF �� O/l' DATE: _ �� ^ 2 L, —OL PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTnER AurnonizED AGENT❑ - IfAPPLlC1NT is not the Blum PARTY.proofofauthorization to sign is required rifle 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 environmenlallsitC assessment' infOl"tiOn 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. oe!'- TYPE OFSERVICEHEOUESTED:• J i L COaaEMS: Qi ay PAYME(v 3 � RECEIVEL , �A J �ZcJ^�/ZoxH/ Nov 2 6 2002 SAN JOAQUIN COUNT PUBLICHEALTH H SE91ICT - APPRbVED D7: EMPLOYEE#7 , AAAA- AAAA AAAA "YYt s ASSIGNED.TO: .. EMPLOYEES# Date,Service Com od (if alreai ompleled): SERVN;E GODEi ['2 Fee'Amount:: -/ Amount Pald ;' Payment Date Z— PaymentType Invoice#` ', ,Check#r RecelvedBy: EH045-01-025 - SERVICE RE0Q6$T REVISE4l;5-02 - . .