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.'IbVHL(UA�VVUIN L k GLV V11iUINIVILIN l AAL AAj--A lU)-11'AK1'1Vl)-Al e <br /> Wi SERVICE REQUEST <br /> Typo of Business or Properly, 41:I;.:SERVICE REQUEST.'#,4 YEN t <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS❑ <br /> A <br /> FAciLo NAME - <br /> I <br /> SITE ADDRESS J 1{J�✓ Dv't LPt � 10,11-V 71J (7 <br /> o <br /> city <br /> HOME Or MAILING ADDRESS (If Different from Site Address) - A <br /> Stmet Numbe Street Hame - <br /> CITY-'i500STA Wb 1 fi"b t--N V tELF3LD G GI 'STATE ZIP <br /> PHONE#1 Ekr. APH�R. LAND USE APPLICATION 0 <br /> 0 , U _ • — - ``ma�y{�p <br /> PHONE q1 Ea. �BQtDISTRIGti7/11P"!9eJ7.�',u'�ee Rol <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR '\NAL— E9 �. <br /> CHECK If BRLINO ADORES$ <br /> BUStNES$NAME. GI'NG1L '(=t�lG lnl�c�L PHONES W ` ' <br /> tag <br /> HOMEor MAILING ADDRESS �"(8 � FAX ) <br /> NA <br /> CITY O I STATE CA ZIP 95246 <br /> y IiI07 A11NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> . ackilOWlCdgC that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or+•„^� <br /> 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 , <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _i� � DATE: Ocil t o�CJ+'2_ <br /> PROPERTY/BUsirims OwrmRO OPERATOR/MANAGER ❑ OTHER AtrritoRiZED AGENTnn. GIyiL <br /> IfAPPUCANT is not the IJ=NGPAR . proof ofauthoriration to sign is required Title <br /> AUTHORIZATION TO RELEASE INTORMATION: When applicable;I,the owner or:operator of the property.located at We=' ''S• <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or cnvirorm entallsite assessment. <br /> infor6tion 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. <br /> :w•. TYPE OF SERVICE REQUESTED:• C< i-rAM t4ATl6N RERx TLn' V—:Er11E5s! NT <br /> � <br /> COMMENTS: <br /> ` � 1u,A7 eLIA/LUAQ,�`o_n64%T.c/t/� �yL�' 1 Q"'^',. /�� ��F P �. 020�►�' ` <br /> ALIwN ouNN <br /> 5P BUONaA`�H�EtNNDVsgI`ji+ . .+i <br /> ENVIRGN,..FN : ..'i <br /> 00, <br /> 1AP R6V DY: <br /> FMPLOYEG#:, 2-y 2 DATE: ( ,. Q "� e <br /> ASSIGNED TO: ,/1y� 4 -/ r EMPLOYEES DATE. <br /> "v"W�� AAAA _ qq��r p <br /> ' Ave VI y -10 <br /> Pato sorviee Completed (If alrWaaj eompieted)t SERVICE CODE' P I <br /> I 31S bD3 <br /> Amount Pald pe E: <br /> pee Amount:;' �',g ymontDate: 9/,1 <br /> . .. � . 111 <br /> Paymont Typo t% Invoice li' } .Check#' c RecolVoci By:, <br /> EHD SED,G;25 11 /fes - 7/ SERVICE REQOWT:ORM 'I <br /> REVISE46;5-02 (OV,ryd . ./� . � - . . <br /> _ _ •war _. ... . -, '. _.._ — _ _-- � _ _ <br />