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6E/P9/2004 15: 30 4640131✓ r-NV.LKLX4ntN1ML r-r' 'r <br /> SAN JOAQUIN C NTV ENVIRONMENTAL HEALTH -ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OMER I OPERATOR <br /> Y��- C 0�r p e��ae,� L L� CNECK N I�ILLINO ADDRt SS <br /> FAM"MW A Ze O -06000 <br /> SITf ADDRESS 0_5- LAS i LGt SSC L' I UE- AT)l�nP Q 33 C' <br /> 8tree Num ftftet DO Ceti* <br /> How or MAILING ADDRESS (if Difremrit from Site Address) <br /> 6 at Nut.7 <br /> CnY STATE Zr <br /> PxM#1 pct. APN 0 LANo Use APPLICATION 0 <br /> ,HOMER! pct, DoS DISTRICT LocAnoNCODit <br /> 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR pAM6t-A CNECKIipbl.IM ADDRESS❑ <br /> P a UT. <br /> 6usiw-ss NAME � V 1P-0Al N'A'SA L. 5'15i"E"�!5 5?�7-&*0C <br /> iiol+ts orMAL04 ADDRESS FAx# <br /> 1�' 3 U I� S�2r.L' c 71#L �— <br /> c1n STATE C4 ZIPc�Z <br /> � L <br /> L yyl,E ; 1, the undersign d property or business owner, operator or authorized agent of Same, <br /> BILacknowicdge that all site and/or projoct specific$NvIRQNMENTAL HEAL-11i DRPARTMENT 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 bave prtpared this application and that the work to be performed will be done in accordance with all SAN JOAQvrtN <br /> CONY Ordinance Codes,Standards,STA'T'E std FnDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> .� �-i 3--cis <br /> PROPERTY/B1JSU`cBaS OWNER❑ OPE TOR/MA �anthcriLRn r sib'" requiredPR&M L`Tc�')4 <br /> If APPMUNY is not the&U .rte proof <br /> :When applicable,1, the owner or operator of the property located at the <br /> ►riTq[112i7eTIpN TO rejeut of any and all results, <br /> above site address, liexeby atrtltorize N IRONMEh AL lltiALTH DEPARTMENT as soon aasta t is available the SRI=tim it t ist <br /> information 10 the SAN JOAQUIN COLM-y <br /> provided to me or my representative. <br /> �jTfli DFSERVICEREQUESTOMitEHTS: KJ r 7� E /•i (.'7 l-7�(`�C /c <br /> k 7�?y 39.0 - 303 <br /> 1 j EIJIPLQYEE DATE. <br /> ACCEPTED BV; DATE: I <br /> I EMPLOYEE#: <br /> I A:SIGNED T0. <br /> SemnCE CODE� j P I f: i <br /> Date Service ComplQtod (tf already complewd): payment Date <br /> ` foeAmount: Amount Fafd <br /> Payment Type Invoico fi <br /> 1 Chock K Fipcelved By: <br />