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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property C� <br /> Residential-Menchaca Property <br /> CHECK if BILLIN_ G�SS <br /> OWNER I OPERATOR <br /> Maria E.Cervantes Menchaca ETAL <br /> FACILITr NAME Menchaca Property 95366 <br /> State Highway 120 Ripon <br /> SITE ADDRESS CI I Coda <br /> StraetNumber 01 111 <br /> Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) treet Name <br /> SVeet Number ZIP <br /> PO Box 314 STATE 95366 <br /> CITY CA <br /> Ripon LAND USE APPLICATION# <br /> EAT. APN# <br /> PHONE#1 <br /> ( 209 ) 610-9109 203-220-760 LOCATION CODE <br /> BOS DISTRICT <br /> PHONE#2 ExT. <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTO <br /> CHECK If BILLING SSO <br /> REQUESTOR Exr_ <br /> Brian Millman PHONE# <br /> BUSINESS NAME <br /> 209 467-1006 <br /> Advanced Geo Environmental Fax# <br /> HOME or MAILING ADDRESS ( ) ZIP 95215 <br /> 837 Shaw Road STATE CA <br /> CITY Stockton <br /> tor or BILLING ACKNOWLEDGEMENT: I, the AL HEALTH DEPARTMENT hourlyerty or business owner, echargesauthssocrized iated witent h this f sap oject <br /> acknowledge that all site and/or project specific ENVIRONMENTAL <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicationad n ERt t e work to be performed will be done in accordance with all SAN 1oAQUlN <br /> COUNTY Ordinance Codes,Standards,STATE � O <br /> APPLICANT'S SIGNATURE: <br /> �� DATE: <br /> ,,��-1I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> PROPERTY/BUSINESS OwNEA1 Title <br /> ff APPLIC.4NT is not the BILLING'G PARTY Proof of authorization able,I,the owner i operator of the prop, located at the <br /> p <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, <br /> geotechnical data and/or environmental/site assessmentH <br /> above site address, hereby authorize the release of any <br /> information to the SAN)OAQU[N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the satll <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 3qN JOq <br /> COMMENTS: ENl// p0/N <br /> H�Cty o��cMLIIN <br /> HT <br /> EMPLOYEE#: DATE: <br /> ACCEPTED BY: DATE: <br /> EMPLOYEE#: <br /> ASSIGNED TO: SERVICE CODE: P I E: <br /> Date Service Com leted (H already completed): Payment Date g <br /> Fee Amount: Amount Paid bO. O� <br /> Payment Type 4 Invoice# <br /> Check# Recei ed By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />