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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> -Type of 136siness or.Property FACILITY ID# SERVICE REQUEST# <br /> r r , <br /> i. C'IT L)0 sgo c)6S 6 <br /> UWNER7 OPE"TOR <br /> CHECK if BILLING-ADDRESS <br /> (<ACIs1TYzNJYIGIEj t"1 ) -5T(. 125 <br /> a z•, �✓ <br /> Str�aDnlss <br /> ( . t ntn 953 <br /> m:�In ! wwY <br /> StreeENumber Direction Street Name Ci Zip Code <br /> £, MctME Or MAl NG AbDRESS.(Ifbtfferentfrom Site AddresS) 456� Yl r S Ca o <br /> Street Number 1" Street Name <br /> " ITYs - STATE ZIP <br /> x <br /> NONE <br /> 1T FAPN# LAND SE APPLICATION#. <br /> rk S <br /> 'NONEExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> w� - <br /> n t2EQUESTOR <br /> �} CHECK if BILLING ADDRESS <br /> J <br /> t{ SINi SS NA1NE \ ` PHONE <br /> I' <br /> DOME O�NCAILING ADDRESS. <br /> FA <br /> STATE ZIP <br /> r 5Wb <br /> BU .INO-ACKN(� LF1DG111k1ENT: I,:the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that_all site.and/or project speck ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project of <br /> ' activitywili-be,billed#omeorm�y:,business..as-identifed_onthisform - <br /> I also certify that lhave.prepared=this application and that the work to be performed will be done in accordance with all SAN JoAQUIN <br /> CdUNTY Ordinance_Codes,Standgrds,.`STATE and. EAE)ZA> laws. <br /> `71A '1(JIGANT°S SIGNATJ DAVE: 16,2_610 <br /> �ILOPERT7f�'BUSINESSOWNEREI OPERATORI:'MANAGER OTIiL+It'AUTHORIZEDAGENT �p /�c �`���f <br /> fAPPLICANI.4's not_the BliL&d PART r proof of authorization to sign is required Title <br /> AUTHQRIATIt1�7 )[EASE -When appllcable�I, the,owneror operator ofthe property located at the <br /> - - <br /> io slte—ad�l�ress, here _a��—ut�icinze _ e release of any:and.all results .geotechnical da�or .environmentallsite assessment <br /> ia- <br /> ormatortfcheAIrI Jt�rt Gt�UNTY:ErrvIItoNMENTAt.HEALTH DEPARTMENT as soon as it is available and at the same.time it is <br /> 4 . <br /> protide to me or my xepresentatrve . <br /> ` � - - - _ - <br /> r. YPEDFSERVICEREQtlESTED - <br /> ,_.__t. _. . ... ED <br /> a3F GDntMrlTs <br /> 7777-7777— -7 T <br /> T q <br /> Fb . W. <br /> . . - SAN JOAQUIN COU <br /> an <br /> E"RONME <br /> EALT-H DEP NT <br /> � E <br /> 14CCEPTEDBY, _ <br /> EMPLOYEE#: DATE: <br /> S I NEDTQ / EMRLOYEE . DATE: <br /> Date erv!Ce Garnpleted (If already completed) SERVICE CODE: PIE: <br /> ter-"• . <br /> -dee Amount_Paid , � Payme Date Z <br /> i <br /> Tvrie1',?4;.A: :i'. Invoice# Chack 9 -1 LMU Rocoivori R%r �1M <br />