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SAN JOAQUOOUNTY ENVIRONMENTAL HEAL 0DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyFACILITY <br />ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />�[II n ac <br />VA10()o 1+E0 <br />5ko33314-- <br />OWNER I OPERATOR /� <br />o L' a,,lo ✓�1' c-- CS�aY e� t"I�l u r ill-n-�L4nd <br />u <br />Owner CHECK if BILLING ADDRESS <br />FACILITY0-C ( M 1 <br />HOME or MAILING ADDRESS <br />1(.0SG( Lu(SL ne� AA�C- <br />SITE ADDRESSI 1 S I ( <br />FAX # <br />(209) <br />�Q GI �1 L f �v e— <br />I <br />V t� <br />CITY 'A-Dc <br />LIQ TT�� <br />q570 -7`f <br />Street Number <br />Direction <br />Street Name <br />Fee Amount: I <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />G( -o o ked S+) C -1L C_, rc_ I e-., <br />49 2 (o' Street Number <br />Street Name <br />I/ <br />CITY /' ft ('F-+ <br />U <br />$T�� ZIP, SZ 1 9 <br />`/ <br />PHONE #1 EXT. <br />(2oq) '-(-73-!177 Gfl;�eo <br />APN # <br />)10 -Z30 -I I <br />LAND USE APPLICATION # <br />PHONE #T EXT <br />(20`i) Q51-(ZO1 (k-Mwr W ani <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR a -R— vi e t <br />( �� <br />(Osf411GtIbh PAYMENT <br />RREGEIVEID <br />CHECK If BILLING ADDRESS <br />CLA uZp I t -t �r1 i1 <br />MAY 15 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />BUSIN NAME <br />PHONE # <br />01 <br />EXT. <br />'/ (�f , rl �OI q <br />HOME or MAILING ADDRESS <br />1(.0SG( Lu(SL ne� AA�C- <br />ASSIGNED TO: <br />FAX # <br />(209) <br />q4-3S(o� <br />V t� <br />CITY 'A-Dc <br />STATE CA <br />ZIP qS 2 0 3 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />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 Colles, Standards TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER El OTHER AUTHORIZED AGENT L7 <br />/f APPLICANT is not the BILLING PAR7'Y, proof of authorization to sign is require[/ Tirte <br />AUTHORIZATION TO RELEASE 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, geotecluiical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII 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: W'T IP1,C <br />(Osf411GtIbh PAYMENT <br />RREGEIVEID <br />COMMENTS: <br />MAY 15 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED BY: <br />EMPLOYEE #: L 'L 'L <br />DATE: S — <br />[ S- — 0J <br />ASSIGNED TO: <br />EMPLOYEE M —76&�3 <br />DATE: (5-- 0 <br />Date Service Com eted (if already completed): <br />SERVICE CODE: <br />PIE: <br />3 c <br />Fee Amount: I <br />Amount Paid <br />Payment Date 5 /� D <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />, <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />