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SAN JOAQUIN OUNTY ENVIRONMLNTAL HEALTI•EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # o c1C, f}'t� ��i� 00 5,2 3/,�)- OWNER / OPERATOR F\ ,tom /� CHECK It BILLING ADDRESS 1 LI e r �� f-\� c, LJ 1\ \- b KY1 pe-�c.A c FACILITY hAME ` t'j SITE ADDRESS 33nu �G-<.tr lO rj R� ��oGk�c, ►1 �S2oS Street Number Direction Street Name CIt ZIp Code HOME or MAILING ADDRESS (If Different from Site Address) (-,C\ e-I%NO C, F- e �' Street NumberF Street Name CITY \':T STATE ZIP �� \tj �-' r X--,GSL0 2. PHONE #1 EXT. APN # LAND USE APPLICATION # OCA )'-I 6z - 310 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 0— 1 �� CHECK If BILLING ADDRESS 12 %o- `� y �J ` 1 V PAY IVI E 17 I RECEIVED BUSINESS NAME /1_ ,�C P" EXT. y b r HOME or MAILING ADDRESS FAX # (9 -CA SAN JOAQUIN COUNTY CITY 't) \'Vo CAc Vo STATE 0— C' ZIP 1311,1ANG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized 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, Slanda s, STATE and FEDERAL laws. 22 APPLICANT'S SIGNATURE: DATE: i7 J PROPERTY / BUSINESs OWNER OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT CL} C A , If APPLICANT s Hol he BILLING PARTY, proof of authorization to sign is required/ Title AUTHORIZATION TORE i ASE 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: COMMENTS: PAY IVI E 17 I RECEIVED JAN - 6 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMFNTAt_ HEALTH DIV!Sr', APPROVED BY: _ EMPLOYEE #: DATE: I ASSIGNED TO: V �� EMPLOYEE #: � 12 DATE: % Date Service Completed (if already completed): SERVICE CODE: C P/E: Z, j O Fee Amount: 7i� " Amount Paid a �� Payment Date J 3 Payment Type C (e— Invoice # Check # G jj Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5.02