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RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN JUL 2 4 2013 <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE <br /> Type of Business or Property _ <br /> CA bL <br /> OWHIrRIOPERATOR CHECK It%1LUNG&PDRERI <br /> C8&L <br /> FACILITY NAME <br /> SJTErADDRESS <br /> HQME or MAILING ABORE55 fit Different from 3119 Address) <br /> iroet N r vee me <br /> CITY STATE ZIP <br /> PH4N6#1 At?i)l LAND W APPLiGA nON# <br /> -x.'760,0 <br /> ISH@NEI EXT. SO$DISTRICT LOCATION AoPE <br /> CONTRACTOR� SERVICE �.EQuEs�ro�a <br /> f�EC1U�9Tpl4 CHOCK if BILItNO AM>�RE38 <br /> PHONE# Exr. <br /> gU8iNL6$NAriAE I_C SE?-o1 cc-.s <br /> HOME or MAILING ADDRESS FAX# <br /> STATE CA ZIP 4�37 <br /> CITY <br /> 183 L61PtG ACKNOWL90GEMI: I, thft undersigned property or OUSIness owner, operator or authorized agent of same, <br /> acknowledge that all 4lte and/or project spoolfic ENvIRONMIh NTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as idantlfled on this form- <br /> 1 also certify that l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY 00nanae Codes, Standards 0 laws. <br /> APPLICANT'S SIGNAT E: -__ DATE. <br /> PROPERTY 113USINP33 OWNER� OPERATO NAOER � OT iiK AUTwRizFD AGENT Q <br /> If APPLICANT is not the ILL Tv,proof of outhor'kOVOn to sign is raquhvd Tui e <br /> A T IZAT N T N M : Voien applicahle, 1, the owner or operator of the prop" located at the above <br /> sits address; hereby authorize the release of any and ail results,geQteehnical data andlor envirorementiailsite assea>Fr�ant inf4ttation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DePARTmrLNT as soon as it is avallalble and at the Same time It Is Pred to me or <br /> my representafive. <br /> f EIV <br /> TYPE OF S2RVICE REQUESTED! � f <br /> COMENTs; 'f,)1Lxr JUN� SAN A 2 4 zoo <br /> N <br /> Eot11N CpU , <br /> HEA�7f-f DFpARTME <br /> 7 <br /> ENi?I-OYEE A -7 f p DATE: 6DZ(r� <br /> ACCEPTED <br /> By. ` `'� <br /> ASSIGNED TO: ><fdPLOYER#: D O j " DATE: <br /> Date Service Completed (If already complete, SEavic>x Coee: 141E: •� d <br /> Fee Amount., 7�-r -- Amount Paid' '7S;O� Payment nate <br /> Payment Type invoice# Check# 1.2-77y et <br /> Re ved By: <br /> EHI)48-02.026 SR FORM(Goldsn Roel) <br /> 07/17/08 <br />