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SAN JOAQUI*UN'I'Y ENV1RONMLWAL HLAL'iPLPAR'1'MEN'1' SERVICE REQUEST Type of Business or Property F / 7— FACILITY ID # SERVICE REQUEST # �f�5 57x1 -T70)11 PHO NE( -v -405257G r=AO�G) 3<vG S'kQC) �% OWNER// FAX # -,OPERATOR 6P �557` Co �t5T /� n RZ 0U C7 GJ L L �i CHECK it BILLING ADDRESS® FACILITY NAME 4kd O J-�SU `/` SITE ADDRESS `7 � ��E`y(p A1 % S Tb G /C TU Tq 5 z 3 StreerNumber Dlreclion Payment Date Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) [ / I e-� 7EF- - lop 1,v 7-9:� Tj R , Street Number Street Name CITY p*e—rn STATE ellIQ ZIP r`Ob ZJ 2 % PHONE #1 EXT- APN H LAND USE APPLICATION # 3335 PHONE G EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR Lo P— / �"e �5�a u �p �`�" ' \ BILLING F / 7— CHECK it BILLING ADDRESS ❑ BUSINESS NAME -T;q / T E� C/ 5 Y,5 7'&-7M 5 opzv ,0/50 y/0c-,e-U12 D/leop7Zd)o1 E&JEN*I A/&--zv 0/0(t)/so y/6 -EV R 1DROy0 7 SE J U L 3 2003 SAN JOAQUIN COUNTY PHO NE( -v -405257G O I /Ocl O ExT. HOME or MAILING ADDRESS FAX # ASSIGNED TO: Mz� EMPLOYEE #: t DATE: 7 3 3 CITY /?)g1k0 lam, e!6/P-Dd 11q STATE n ZIP q5-742- 5.7[7Z BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL I-IEALTII 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: � e �� DATE: PROPERTY / BUSINESS OWNER ❑ OreRnTolz / MANAGER ❑ OTIILR AUTIIORIZED AGLNT - 1ea tf APPLICANT is Hot the BILLING PARTY, proof of authorization to sign is required . Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 LNVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REOUESTED: F / 7— COMMENTS: COMMENTS: REf'l C6 --D C/577A16 l /°ko nl�.C-r 607TH opzv ,0/50 y/0c-,e-U12 D/leop7Zd)o1 E&JEN*I A/&--zv 0/0(t)/so y/6 -EV R 1DROy0 7 SE J U L 3 2003 SAN JOAQUIN COUNTY APPROVED BY: EMPLOYEE #: 2C1� FIQAIiET1IJf.ILO b'ISb'if ASSIGNED TO: Mz� EMPLOYEE #: t DATE: 7 3 3 Date Service Completed (if already completed): SERVICE CODE: �� PIE.�130 f Fee Amount: 70o Amount Paid 247 Payment Date Payment Type L/ 7 Invoice # Check # 4-7-79 Received By: EHD 48.01.025 SERVICE REQUEST FORM REVISED 6.5-02