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P, <br /> u ;Fa C�- A sv tU S Uf,3 T�A C F- C- M`UIQ (mnq-1 <br /> SERVICE REQU ST <br /> Type of Business or i—� <br /> ty FACILITY ID# <br /> }�01�1Fs31 i' �tctAR-rOW6-K AP�4; A SERVICE REQUE T# <br /> �-- <br /> OWNERIOPERATOR 1:97� �� Mte � CSZav �2aA� <br /> AiZI. S;E�L RS L ori , C�L, c�u w VA, 195.2 4tD BrwHc PARTY❑ <br /> FAciLr Y NAME N,A <br /> SITE ADDRESS <br /> la9-1 q <br /> SVattNvmbr Mrccvon SV�HHamf <br /> Mailing Address (if Different from Site Address)- REA 6{RG� Tom• s�un,r <br /> CRY GALT It STATE <br /> STRxs.' SUS C, <br /> STATE CA ZIP 95b32 <br /> PHONE#1 �. . <br /> tzc8) 7q.S` Z%o� APN# OAS --21 U� 37 LAND Use APPucATION# <br /> [PHONE 92 Exr. BOS QISTRiCT <br /> LOCAT1oN CODE <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR <br /> WA'L-7 G>J W.S BILLING PARTY <br /> BUSINESS NAME r tv+L PHONE# Exs. <br /> MAILING ADDRESS 1$ M Ar Ww <br /> FAx# <br /> PLA'Z N/A <br /> CITY �T�1y C,4LtFc�t2t�tiA 9524a S�tTE-� -gyp' <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator o authorized agen of same, acknowledge that all site and/or project speciric <br /> PUBLIC HEALTH SERVICES ENV:RONMENTAL HEALTH DNZION hourly charges associated with this projector activity will riled 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 ail SAN JOAOUIN,COUNTY Ordinance Codes,Standards,STATE and <br /> l;EOERAL laws <br /> APPLICANT SIGNATURE: DATE: OS/14/2( <br /> PROPERTY ISUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> YAPm.-wrisnolfheAI{TY Ti!!e <br /> &!y2A "PmOf of au(horizaflon to sign is rorfuirvd J <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property roared at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data andlor environmentaVSile assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTIf SERVICES ENVIRONMENTAL HEALTH D€ ioN as soon <br /> as it Is avaitabie and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RF:�ytIE�W it 5L3V-r-pC:1--- ^" <br /> COMMENTS: <br /> `y'MENT <br /> i <br /> F E <br /> o CEIVED <br /> MAY 14 2U,191 <br /> SAN JOAQUIN COUNTY <br /> FNVJR0NtaN Aj.HEA TH p V SION <br /> INSPECTOR'S SIGNATURE: <br /> CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYE[#: <br /> �A,, � c--�.�✓ t DATE: <br /> ASS€GNED 7o: {i ins EMPI OYCE#: ( C19 <br /> l `1 � DATE: <br /> Date Service C mpleted (if already completed): <br /> S ERVICE CODC: <br /> Fee Amount: O 5 PIE:. <br /> Payment Type I ' <br /> Amount Paid b� payment Date <br /> � -f <br /> P Invoice# Check# <br /> Received By: <br />