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Type of Business or Property SERVICE REQUEST <br /> FACILITY 10# Y <br /> AGRt CULMRA�. sERVICE REQUEST# <br /> �, . zss-34.-e7 52 c��2�� <br /> OWN ERIOPERATOR LISA w1°Rb <br /> BILLING PARTY 0 <br /> FAciunr NAME WARL FF-AL- VESTA-s'E <br /> SrTEAODRESs 146WE ASS r," �l]R�1hM SER OAS q$OtsT <br /> Sesu 1 �f;�I`T�' tis'r �aSEcT►oµ t�KAP <br /> she�tHumher Gkectian brippM�E�R71tgy StrtitRxneq�ybAlRR�.Tw� T <br /> Mailing Address {lf Different from Site Address} AcC-35 -�15T Sr cSF�vt2 p,y svlt.e <br /> fiERI2 a a� <br /> 1034 CE"I RAL Eku'E. <br /> k. CITY 'TRAc`/ STATE CA ZIP 953'? ^39 i 5 <br /> PHONE#') . <br /> (&X4 8�..14-c4- APN#Z%-34-07 LewD USE APPLICATION# <br /> PHONE#2 �. <br /> 2Cfl "83b_�, SOS DISTRICT LocATIok.Coot <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REaUESTOR 1NALTFR. e, CUW-TIS <br /> BILLING PARTY I j <br /> BUSINESS NAME GIYIL' MC21uME�R- <br /> PHONE Exr. <br /> I!'IIULING ADDRESS qi 8 MA EW PLAZ# FAX# <br /> STATE CA Zip1� Lz n <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SER CES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me 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 COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws <br /> APPLICANT SIGNATURE: DATE: OI 6� <br /> wA1rTMetr. GUR.TIS .. <br /> PROPERTY I BUSINESS OWNER. ❑ OPERATORI MANAGER OTHER AUTHORIZED AGENT <br /> ff APauG W r is ratthe /a�rurhoriz�(fan ra sign IsmquU»d True <br /> AUTHORIZATION TO REiEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentatlsite assessment infomlation to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EwRONmENTAL HEALTH DrwsiON as soon <br /> as it is available and at the same time it is provided to me or my representalnre. <br /> TYPE OF SERVICE REQUESTED. Soli. SVA VAgIL% y STUby REJ:,01P!7r peyl: .W <br /> f <br /> COMMENTS: PAYMENT <br /> RECOVER <br /> 0 JAI 2 9 2002 <br /> pro, SAN JOAQUiN COUNTY <br /> _ PUBLIC WEALTH SERVICES <br /> LTJ ENV#RONMENTAI- HEALTH DIVISION <br /> t <br /> INSECTOR.s SIGNATURE* � . <br /> CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:.' EMPLOYEE#: 7 <br /> �. DATE: G <br /> ASSIGNED TO: � EMPLOYEE#: ' <br /> 7 DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE Caat: Z P I E:. <br /> Fee Amount: �D Amount Paid Ni <br /> Payment Date 1/2-9/0L <br /> Payment Type a� invoice#' Check# <br /> 430 Received By <br />