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f <br /> 1 <br /> SAN,IOAT7UIN4C0UNTYENN11RON'ME\TAI,IIEALTII DEPARTAIENf <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST It <br /> 3 DU8a348 <br /> OWNER I OPERATOR i} <br /> 9-o'LA �DY1 Or t� <br /> FAwrtlii tE <br /> OV VU Y �\0 <br /> SITEAMMS E, 4,aa Sc PUC Lo,J+I OOP C)5390 <br /> Z �ma„ <br /> HouE of MALm ADDFESS IR DiRenm from Site Address) CPI 8533 <br /> 5 t T Nvm4n <br /> Cin' V\ STATE LP <br /> CA <br /> S3 <br /> PWNEM Eo. <br /> APN0 LAND <br /> � bo - 2JB0S;7"`"8 <br /> PMK12 <br /> tacAnaicooE <br /> 1 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR ,f <br /> *�l/�� CNFCx i}Bn4A�4 ADd!E51 <br /> BusmESs NAME PRDYEt En <br /> Home or MmL=ADDRESS FAX 1 <br /> 1 1 <br /> CRY STATE LP <br /> BILLING ACKNGAVLEDGEMFAT: 1. the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site and:or project specific F.vvIROaTfiDnAL HEALT11 DEPARTNorr hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certifi-that I have prepared this application and that the work to be performed wil done in accordance with all SAL%JOAOLI', <br /> COL'%-ry Ordiwnce Codes.Srandar ,b ATE an EDFRAL laws. 7, <br /> APPLICAN'T'S SIGNATURE: ,J " DATE: I23�W I <br /> PROrERn'(&RL%TSS OwN-ER O ORINIAVAGER OTuERAL 110R17IAAGL.%7❑ <br /> LJ <br /> f APPLX'A.%T ismi the t eRN proof of authorization to sign Is required T7Ur <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all resulm geotechnical data and:or environmentalsite assessment <br /> information to the SAN JOAQUIN COLN T"N'F-WRONS04TAL HEALTH DEPARTSUNT as soon as it is available and at the same time It is <br /> pro%iced to me or my representative. <br /> TYPE OF SERNCE REQUESTED: - M <br /> CDiRW7 <br /> JUL 3 p 1020 <br /> ORONM O <br /> HE ENV <br /> At <br /> AccEPTED BY: ✓K�SLO EMPLOYEE R: DATE: <br /> ASWGKD TO: yl avY,C� EMPLOYED>y: DATE: <br /> Data Service Completed pf skaady cumpistao: SUNCE CDOE: PIE: I &02� <br /> Fee Amount 1,0 <br /> Amount Pal C2 on Payment Date <br /> Payment Type Invoice n 1 Check N 2 33 aceivEd By: <br /> EHD 4W2-O,S SR FORM(Gddm Rod) <br /> REVISED IL't7r= <br />