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74W, � ...,yri e�.�r � s... .. ,:.. ..... ..._.. � 1�fir�t'�3 m�.i't:':v".2 ,,• '��i�f. `'�' <br /> NOV 21 2000 3:25PM HP LHSERJET 3200 P•3 <br /> SAN JOAQUIN COUhr 1'Y ENVIROIVR11,0TAL 1"(I.Al,I'H DKI'AIYt'MENT <br /> SERVICE REQUEST <br /> Type o!Business or property <br /> p y FACILITY IO p <br /> SERVICE REQUEST p , U, _ <br /> X1 ©-A 4(ppgq�� o , <br /> OWNER P RA — <br /> G�<� <br /> CHECK KE ILLIND ADDRESS 1, - <br /> FACILOY NAME <br /> SITE ADDRt:SS �• p ,_.`�� r� � �. <br /> Slrtet Nurnher If coon ,-�1i Neri wa`me�e^f it ti Codt <br /> 7HOMEOfNG ADDRESS (If Different from Site Address) <br /> $TATE 21p <br /> i <br /> PHONE X} E.r, APN V LAND USE APPLICATION# <br /> Ii 1 <br /> ;'. <br /> PHONE f12 E T• 00S DISTRICT LOCATION CODE <br /> 1 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> L(QUTOR <br /> CHECK If BILLING AODAE55 <br /> sNAME PHONE Eur. <br /> NOME Of MAILING ADDRE S FAM p <br /> gD 1 ) <br /> CITY <br /> STAT 2 n <br /> 1311.1,ING ACKN0Wl.FDGF,MEMU 1, the undersigned property or business owner, operator or authorized agcltl of same <br /> acknowledge t11al all site and/or project spCCific E-NVIRONM 'Nut-HEALTH DEPARTMENT hourly charges associated with this project or `. <br /> cuvlly will be billed ID me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and 11131 the work to be performed will be done in accordance with all SAN JOAgUI- <br /> COUNTY 0rr1irtanc•e Codes,SfcnrdurdS,STAT(?and r ADERAI.laws. <br /> APPLICANT'S SIGNATURE -2- <br /> DATE: <br /> PKOrERTY111051NF.SSOWNEIt❑ 01-ERATOR•/MANACF11 ❑ OTHERAUTIIOtttzP.OACF r <br /> lf/JYNLIC:ANT's Hot I/le U.I.INCAdRTY prOOf 01a"1110H fion to si to iz regrrired Tule <br /> AUIrtiOR17,ATION TO RFT EASF INFORMATION: When opplimble, t, the owner or operator of the property located al the <br /> above site address, hereby audTorize the release of any and all results, geotechnical data andfor environmcnLTl(site assessment <br /> ialbrnia:ioh to the SAN JOAQUIN COUNTY ENVIRONMM- TALMEAl:ril DCPARTMENT as soon as R is available and al t llsi pTrF Iin7C Il is <br /> provided to me or my representative. PA <br /> 1 V <br /> TYPE OF SERVICE REO smc: <br /> ih <br /> CONVENTS: <br /> SAN JOAOUIME TMENT <br /> HATH DEPAR <br /> 7 APPROVED BY: f <br /> Xll;'' EMPLOYEEfI: �[ DATE: 2�� <br /> ASSIGNED T0; F EMPLOYEE 0: Q DATE' 1/ `rV <br /> „nN l <br /> Date Service Completed (If already compleled): SERVICE CODE.- /g PI E.Z <br /> Fee Amount: A9 Amount Paid �� !�' v Payment Dato J( <br /> Payment TypeInvoice A Check ft <br /> Received By: <br /> EHO 48-07.025 <br /> QFVISED 6.5.02 SERVICE REQUEST FORM <br /> Z 'd '' bTbLLE660Z JaaT -A U04A004S JO 61T3 eS0 :80 SO BZ AOW <br />