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SAN JOAQUIJN COUNTY ENVIRON-MENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Schm) I SOQWva3 <br /> OWNER I OPERATOR ^- Y�'� (J'tl <br /> SQYS 3D4 LC(11 l.otLICP V1 (t <br /> NLa rise r.NECK I(&LUNOADDRF55o <br /> FACiLn NAME one..Li � l <br /> SITEADDReSs g31�} �1eWo�re Aveq( }p�� g520y <br /> Street Number I Dlwflon Street Name cityI Cotle <br /> HDME or MAILING ADDRESS (It Different from Site Address) 270 7 Tr ao-s v ir7r ld fir, <br /> Street Numberstreet Nam <br /> CITY Qy�,^�j n STATE /t/t LP <br /> PHONERt Jt VI- TLJ EXT. APN# LAND USE—APPPPLicATIDN# <br /> (ZMI 4rv�s- go1Fr <br /> PHDHE712 DOS DISTRICT LOCATIONCODE <br /> (meq) t9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Canine Waiyher <br /> CHECK if BILLING ADDRESS <br /> BusmEss NAME PHONE ,I�Fj 6 �EXT�gLlln Coun+tice o E V' o -Mol <br /> HOME or MAILING ADDRESS 27c)7 I>2tnSWOr Id r FAX <br /> X# g�_ gayr <br /> CITY yy, �� r K JW STATE 0)k <br /> ZIP q 5213 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business winer, uperator or aulhori,ecd agent of same, <br /> acknowledge that all site ari"r project bpecilic GNVIRo\:AIL\IAL IILALrn DLPARINL\1 hourly Charges associated %with this project <br /> or activity will be bitted to me or my husiucv%as identified on this tocol. <br /> I also certify that I have prepared[his application and that the work to be peifomled will Ix:done in accortldnee with all SAY JOAQUIN <br /> COLT Il' Orrliuuuca Crulrx,S'landarrb', '�T'L and FEDERAL IewS. �J / �f <br /> APPLICANT'S SIGNATURE: r DATE:aI '7-/ <br /> PROPERTYI BUSINESS OtrNERO OPERATORINItNACERO OTIIE :V-TIrnRI7FII/ACE�T I)0 /4(�-Tr LrID/ , II P�( .�IrJ� <br /> J1'.1PPL1C4A'l ix not the BILLING P4R7),proofafaathorkude r resign is required Title <br /> All ITHORIZATION TO RELFASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the rclLasc of any and all results. geotechnical data andfor environniontalJsite assessment <br /> iufalnn.Ition Io the SAN JOAQt'IN COLINIFY E\'VIRONAIL.NIAt.I MAI TIF DFPARTN1r\7 as soon as it is available and ut the some link: it is <br /> provided Io me or my representative. rm <br /> `�' <br /> TYPE OF SERVICE REQUESTED: tk'o 57C D-C- S (tl-�,-_ RECEIVED <br /> COMMENTS: AUG 0 3 2021 <br /> SNN JOAQWNDONTY <br /> "T"N... <br /> T" NMEN <br /> ' HE�LTN DEPPRTMENT <br /> ACCEPTED BY: �! r��S L� EMPLOYEE#: DATE: <br /> ASSIGNEDTO: D�ld 5 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z PIE: a <br /> Fee Amount: I STS Amount Paid ��Z— Payment Date <br /> Payment Type Invoice# Check# AD y�q 3 z,g Reeelved By: <br /> EHD 48-02-025 SR FORNI(Golden Rod) <br /> REVISED 11/1712003 <br />