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SAN JOAQUIN ('()UN'I'Y L''NVWONMLN'I'AL HI;AL'1' EPAWI'MBN'1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> TSA CC 3 4�- 27 <br /> OWNER/OPERATOR f3 <br /> n <br /> lc)6 go4' CHECK If BILLING ADDRESS❑ <br /> G�`s <br /> FACILITY NAME <br /> SITE ADDRESS 4600 ���n <br /> Ut/C DAK" TL-oD 7- <br /> ��5 ; <br /> Street Number Direction Street Name CIl 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3L76 64-.6. c-9-tiy,,_ elj <br /> Street Number Street Name <br /> CITY �1 V L STATE C, ZIP <br /> 't 9��Fft1 <br /> PHONE#1 EXT. APN# <br /> LAND USE APPLI T Nor# <br /> U`:, <br /> PHONE#2 EXT. ' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ �7 <br /> T "�I CHECK it BILLING ADDRESS❑ <br /> BUSINESS NAME \/ ,� PHONE# EXT. <br /> ?,c,., '334- 66/ 3 <br /> HOME or MAILING ADDRESS ��dd �,jyZ n FAX# <br /> P. � . avx �-(�o - 9Sa� <br /> CITY c �� <br /> t,L.i7 { STATE ZIP <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 Ine 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 Codes,Standards,STATE anFEDERAL laws. <br /> APPLICANT'S SIGNATU �% 0-;DATE: <br /> PROPEWrY/BUSINESS N1,R❑ OI-EIZATOR/MANAGCIt ❑ O"ri mit AIT nORIzLD AGENT <br /> If APPLICANT is not 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: lV ��� 1�- , -�i� 1 „ <br /> COMMENTS: f 1�61U'Wvl�w <br /> V JUL 12003 <br /> �J � <br /> SAN JOAQUINCOUNTY <br /> F-�fi1.f �...� PUBLIC HEALTH <br /> SERVICES <br /> VU j U ENVIRONMENTAL HEALTH DIVISION <br /> At 6- <br /> APPROVED BY: l a—Aj ) EMPLOYEE#: 'Z L DATE: N -03 0 ✓ <br /> "j <br /> ASSIGNED TO: J EMPLOYEE#: DATE: —7I V `- <br /> � l <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P I E: (� <br /> Fee Amount: -� Amount Paid Payment Dale <br /> Payment Type <br /> In <br /> # Check# Received By: <br /> EHD 48-01.025 SERVICE REQUEST FORM <br /> REVISED 6-5.02 <br />