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L.01 <br /> SAN JOAQUJD COUN FY ENVIRONIMENTAL HEAL'T'H DEPARTMEINT <br /> SERVICE REQUEST <br /> Type of Business or Property `rACIUTY ID# SERVICE REQUEST <br /> OWNER OPERATOR <br /> CHECK if BI>_l1Nc Ar70RF55 <br /> FACiLrrY NAME <br /> SITE ADDRESS 0-7 7 <br /> street Numher Direction Street Name cm ZJp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumSer Street Name <br /> CITY STATE zip <br /> PHONE I APN# LAND USE APPLICATION# <br /> PHONE#Z -XT. SOBS DiS T R IC T CCL- <br /> 1 <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REQUESTO i CHECK if BILLING ADDRESS <br /> BUSINESS NAME l' NE E"' <br /> : d g3 -D 5g <br /> HOME DC M ffNG AE$$ FAX# <br /> Z G �is' / <br /> I CITY fC�. ; STATE�IA zip 95 7 <br /> r g �J <br /> d b e, <br /> a site an o A our yt <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with SAN JOAQLI <br /> COLTNYrY Ordinance Codes,Standards, STATE,and FEDERAL laws. } <br /> APPLICANT'S SIGNATURE: ^�i ill e� DATE: rt Z J <br /> PROPERTY/BusrgE s owNT.R❑ ER;TOR/\MANAGER TRERAUTIIORIZEDAGENT <br /> If APPLIC,iNT LT not the B=A'G PARTY;proof of auihorizadon to sign is required Title <br /> A77HORIZATION TO IREF�LF.ASE INFOR-MATION: %Vhcn 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 environmentallsite assessment <br /> information to the SAN;JoAQUt?I COL'.'11riY a, -rAL HEALTH 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: _ll <br /> COMMENTS: '�PN04 <br /> j,,EC0VED <br /> i DEC 31 ZW <br /> I <br /> SAN SOAQUIN CO A TY <br /> APPROVED^-Y: ALTf-���y D A 7 <br /> I ASSIGNED TO: ��`l"� EMPL4YEE". � DATA: <br /> .laie Service Completed (if aircaciy compier�c): _cr.VICE CODE: y p 1 E: ' <br /> Fee Amount: AM. Cunt Ppid XP�'��. 6.0 Payment Date <br /> 0�3&2;' <br /> I ?�vrnent Type ]nvcir_- Check# Received By: - <br /> ERD 4"1-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />