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S AN JOAQUIN COUNTY ENVIRONMENTAL HEALTO-DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# A COZIC,) •SU RU APtd; 429-ZZO-c 24, 625 73R-U C� 3 OWNER/OPERATOR ,Toe SUTRA JP- JTi�£PFl Rtxr4l5 ❑ CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS l�.. lt7 VtcTn��' READ 9rJ3�c1 Street Number Direction Street Name Ci ZIP Code HOME or MAILING ADDRESS (If Different from Site Address) Iia STA'r1A 1'C�1ZD A V G NU$ Street Number h�" C_ Street Name CITY M STATE CA ZIP 9535a oDE3�'o PHONE#11 ExT' APN# LAND USE APPLICATION# (cV9 ) 5+-+- 704-'O ZZ9'-?2n -n24, n26 -/?� _D-?-1- PHONE#2 ?-1-PHONE#2 ExT SOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR WAL759, 17- , Gu5zri.J, Ci'v IL r„Iy(71 CHECK if BILLING ADDRES BUSINESS NAME PHONE# Ex. cLyRTts Et(�tutirEry2tII � 2'* 3C�g- 4 HOME or MAILING ADDRESS FAX# -+l e IATCEW PL zA CITY L e=b I STATE G,A ZIP 9524-O BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or ag horized 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 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: t t •k _A,h � DATE: 0±5/0,5/24-- PROPERTY/ 5/05/04-- PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT (fAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required i# Title 115g4- 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 environmental/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. TYPE OF SERVICE REQUESTED: P vI1FWo= Su R.aF'A�E. SUs vC F'AG1s t�tyT-gMllvATT 6T.i rc c6 COMMENTS: �_ 3-dS Ya Y rPAYMENT RECEIVED MAY 3 2004 Y" OLTY SAEOEANRONAOUI MrhWt4T APPROVED BY: CLI VLl {—_,t EMPLOYEE#: 0 -32-1 DATE: ASSIGNED TO: -Foe-I n, in A-8 is EMPLOYEE#: (j U I �/ DATE: Date Service Completed (if already completed): SERVICE CODE: 3 tJ PIE: z 03 Fee Amount: �( , Amount Paid $ ( a'D Payment Date S 3 t7 LI Payment Type ✓ Invoice# Check# 01-1 Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 65-02