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SAN JOAQUIVOUNTY ENVIRONMENTAL HEAL *EPARTMENT <br />SERVICE REQUEST <br />__j Type of Business or Property <br />ID # <br />SERVICE REQUEST # <br />GAS STATION <br />r_ �FACILITY <br />1'� �5' <br />"' 35'7 qZ <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESSE] <br />FACILITY NAME <br />SITE ADDRESS -71 <br />1 (Street <br />w V <br />t <br />19,5_2 Ll b <br />Number. <br />Direction <br />Street N e <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CIN <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />U -.a I OR <br />Tr as�iA4t'rL`TE IV CONTRACTORS, uC. PHONE# <br />Int, ADDRESS --------- - — _ —. _----- FAX# <br />2535 WIc'WE�i'i (209) '161-5 3 <br />" Y STOCKTON STATE CA <br />]ALUM%7.-`_wICN0WLEDGEMENT: T, the undersigned property or !rosiness owner, operator or authorized agent of vaine, <br />a&.nowledbe that .-;if site and/or project specific ENV IRONIVIENTALHEA,-TH DEPARTMENT hourly charges associated with this p7oiixt or <br />Z, ,1vity will be ;hied to me or my business as identified on tris form. <br />s rsf �.rtify ;,,r.. I h;-ve prepared.i:iis application and dmt thf in `.. ,erforrned will be done in ",,Ince w;°i, Jc <br />Codes, Sta..yav, <br />-ds, STATE a it <br />IE,1`':�TURE: DATE: _ O <br />Y. li/ U:t 'J_ , Y .j'' ��G� c ii L 'on _':i S c ft is requii `. <br />F' ? rO RELEASE. li*41FORV''•e owner o* op r^ tot <br />site rl .: c. ,. iereby authrri?e the rele,,,c of iiy ;;,: geotechnical iia: and/c.- enviror_.iie, ,I/s,�, ,.. r.. <br />•..tio<< io . .. _; .N JOAQUIN C DUVTY ENVIR0 TMf.NT,. licAi_7H :?:- •'ARTMENT as soon as it is riviliLble and 11 <br />••d-„ tr. in representative <br />C tt� SERdi r'?!-C'IESTED: 1�'`� PAYMENT <br />- IREMIUE-D-._ <br />OCT 2 3 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />.(ATF. <br />!:',AFLOYEE <br />+.-i:5, Service Co-ipleted (if already completed): - <br />Fee Amount: Amount Paid <br />P Payment Type* <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE CODt: F E. <br />Payment Date ( O� <br />heck #- _ <br />% ��_d 'sy: I/ /j I <br />SERVICE REQUEST FORM <br />