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12/22/2003 17:02 209577GA40 BOYETT PETROLEUM PAGE 02/02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMF,NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 0 3 6 5 s K CO' -3,6, �� s— <br /> OWNER/OPER"' <br /> Lr-['r' �I CHECK if BILLING ADDRESS <br /> FACILITY NAME • 1 <br /> lewtK Ss QJ <br /> SITE ADDRESS <br /> 11M A-t,r „S <br /> y1q Street Numbar DiroGtton Ai Stry N � Zin Coda <br /> ��� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Z-7-1 StreatNumbar <br /> et Namo <br /> CITY � STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> i216a) 5-1-7. <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> l 1 <br /> ?f-$9-19� 7� <br /> CONTRACTOR/SERVICE REQUESTOR <br /> iREQUESTOR 51r.1--cm <br /> If BILLING ADDRESS <br /> . � _ 571.E <br /> BUSINESS NAMEPHONE EXT, <br /> BON�' vl w� zv9I5�T'7- <br /> HoME Or MAILING ADDRESS FAX# <br /> •0 . 4O x S'71v2'T� 1 SS'7'7�- d <br /> CITY O "`� STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or nuthorized agent of same, <br /> acknowledge that all site and/or project Spceifie ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa,-ds,STATE and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATE: 03 <br /> — A <br /> PROPERTY IBUSTNFSgOWNEIt� OPRRATOR/MANACF.R� OT}IERAUTHOR1ZEDAC:ENT© GPCl2tI'0I^AA46 1"W101�f� <br /> IrAPPLlCANT is nal the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHQRJZATION TO RELCASE INFORMATION: When 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 environmental/site assessment <br /> information to the SAN JOAQUIN C0IJNTY ENVIRONMENTAT,HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my rcpresentative- <br /> TYPE OF SERVICE REQUESTED: C9 <br /> 4 r f \\11�E1 i <br /> COMMENTS: PAYMENT <br /> I <br /> RECEIVED 2�Q� <br /> DEC 142003 DEC, <br /> SAN JOAQUIN COUNTY l <br /> APPROVRD BY; l"1 A E 3� -7DATE:ASSIGNED TO: VOA I�`�� EMPLOYEE#: (� 3 IDATE: t �� <br /> D1te Service Completed (if already completed): SIeRVICY CODE: ' Q p 1 /► b <br /> Fee Amount: Z'I 4J , �� Amount Paid Z 7�. 0Q Payment Date L 2 Z V A <br /> Payment Type 1 Invoice# Check# ` ( Received By: <br /> EHO 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6.5-02 <br />