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D)IF <br /> /28!2003 10:43 4640138 ENVIRONMENTAL HEALTH <br /> +SAN.J OA.QUIN C*T Y I;I NY,IRONMEN T'AL HEALTIi AkAWME MY ,,. <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY lDSERVICE Fii:fl HEALTH <br /> u�- rev is� I =1�- ► <br /> T+A 0 cc I ��d S �C�� 3 9'' 51 <br /> 7''"rise v�cE <br /> OWNER/OPERATOR <br /> CNFCKH 54.61NG ADOREss <br /> 4 41- <br /> Fern mr I1f4ME <br /> SITE ADDRESS _ .� ���A �Zi0 <br /> Stmel Number L" Ion IV, <br /> t e Name Clt o <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Sireet Number Mgme <br /> Cmr <br /> STATE' 75P <br /> PHONE 91 . rxr. APN# LAm,U•ss AtpucxnoN 8 <br /> PHONE YZ W. SO$.DUMICT � LOCATION Coot <br /> { <br /> CONTRACTOR/SERVICE REQUE8TOR <br /> RE UESTOR <br /> • � 'CHECK IIBILLTNGt10OR_ESS� <br /> BUSINESS AAME PHONE EX'' <br /> HOME or MAILING DDRESS aj ; FAX I! <br /> t✓tTY. J��ad�C.d.. `.�T STATE ZIP <br /> RILI,iNG ACKNOWLFt)(;r_,mENT: 1, the undersigned property or business owner, operator or authorized agent of sonic, <br /> acknowledge,that all site and/or project specilie ENVI110NMENTAL UEALTtt br�PAtt'im NT.hourly charges assoclated with this project or <br /> activity will be billed to me or ray business as idcntiFed on this form. <br /> I also certify that.I have preparedth- plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa d ATC an GDLRAL laws. J / <br /> APPLICANT'S SIGNATURE: DATLO: �Ir C�� -- <br /> Pitor"tifiTYI oustrun OwNxit❑ 0?9R TOR/MANACra E3CTuaR Au ni(Jrt m ArXNT CCakU�: <br /> If APP1;.IcANris►totflee dtLG1NG PAS prvof vf'au11toriWMn to sigis Is'ragrtirad TF�fc <br /> AUTH0IZI2i1TI0N TO R-rummsF,INFORMA'I"iQ1J When applicable,I;the owner or operator of the property located at the <br /> above site address. hereby authorize the release of any and all results, geotechnical data anal/or enkiro:imctstal/s:tc a=sment , <br /> information to the SAN IVAQUI14 COUNTY 5NVIRONMEN'rAL HEALTH DEPAIt't'NtmW as soon as it is available and at the same time it is <br /> provided to me or representative. <br /> TYPE QF SERVICE AEfauI:STED: Us" ( r o f <br /> RECEIVED , <br /> JUL 10 2003 <br /> SAN JOAOUIN COUNTY <br /> I PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED SY: '61 EMPI.oYEE 0: 'L WE: <br /> AsstGNED'Ta: v j EMPI.oXEE#: DAT E- - to- — 0_? <br /> Date Sorvlco Completed (I(already completed): SERVICE CODE: � { Q 1 ,/" <br /> Fee Amount: � �" Amount Ptlid Payrnant Date, <br /> Paymeni Type invoice!� I Check# jj� Received t3y: <br /> EH0 48-1 14Q,S SERVICE REC}UEST FORM <br /> REVISED 6.502. <br />