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i,)eek i 's G--C)t cl - <br /> `+ SAN OAQ1* COUNTY ENVIRONMENTAL HEAI6DEPARTMENT <br /> SERVICE REQUEST <br /> Type pf Business o Property FACILITY Id# SERVICE REQUEST# <br /> OWNE /OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> ,. e 1N� r <br /> SITE ADDRESS 2 C—) �1 <br /> v .G �J Gee c� 1 c�o cc\ `Sc►�1 o r1 ej S.? <br /> Street Number Direction Street Name <br /> �_ City Zip Code <br /> HOME or MAILING ADDRESS n(if Different from Site Address) <br /> d o `♦ ` �, Street Number Street Name <br /> CITY STATE ZIP <br /> PHONEA1 ExT. APN# LAND USE APPLICATION# <br /> '001) %1 6Z3 — H l ry <br /> PHONE#2 Em SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SEFYICE REQUESTOR <br /> REO' :JR <br /> CHECK If BILLING ADDRESS <br /> Q L� <br /> BtiSINESS t.'AM FyLt ,( l ` \�')J L� j PHONE# T' <br /> j f <br /> . <br /> ,CIZ _ �1 4, t'' , - ier, <br /> • _ <br /> acknos, t_-eg that all site and/or project specific ENVIRONMEN-fAL HEALTHcaargcs associated with this projezt or <br /> activit,l w ,' ,,,,.6ilied to nie.or amy business as identified on this form. <br /> I a. : c' Iii, ihai : iiavo ,%-eoarcd Fills l r I.c<�r.:.. I and that . ;.v F, ' :'1l_-171!%1711(0 v,;I1 be l iii In zlcc7 .,t2:^ct + all SA14 ' <br /> COUNTY Ordinance Coc,'_s,�rtrailIr r'arfi r n%: r.i_Iawr. <br /> APPLICANT'S SIGNATURE: -�CC `(`�LSZ �i� Q�� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTIIFR AUTHORIZED AGENT <br /> If APPLICANT i the BILLING PARTY,proof of authorization to sign is required Title <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, geotechnical data and/or environmental/site assessment <br /> infomiatioh to the SAN JOAQUIN COUNTY ENVIRONMENTAL I-!-A1.TH DEPARTMENT as soon as it is available and at the same time + is <br /> provid,A to me,or ary representative. <br /> -�i HYPE Of: E;'`J4rE REGI!"STEO: RECEwEQ <br /> GO�MEtiS: <br /> OCT 2 7 2004 <br /> I SAN JOAQUIN COUNT`( I <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P t E: <br /> �.7 7 <br /> Pr;r,n:nt Type ✓ Invoice# i C) .t o�: # v 0 —� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />