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it SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID M OWNERIOPERATORl r /) r CONTRACTOR /SERVICE REQUESTOR REOUESToa,( . n4W � I , ! O CNacK Ht3aL[N Aoorraat BUSIraE3 wA.te /40vE EYr. 401,. o/, d �_ t. ;toy7- HouE or MAA -mo ADDRESS FAX Cm " 1 . 7q cf STATE A ZIP X533 BI_I.LINC ACKNOW! DGEM N'r: 1, the unders.{limed property or business owner, operator or authorized agent or tame, acl:nowk-dge that all site an&or project specific FNVIRONAIEN'fAL HFACrH DFPAIpTdLNr hourly charges associmed with this project or activity will be billed to roe or my business as identified on this form. I also cenilk [hat I have prcpwrd this application and that the work to be performed will be done in accordance with all AN JOA LIN S COUNTY Ordinance Under, .Standards S, and FEDERAL la/ws. ��,, APPLICANT'S SIGNATU—R/E; /�+ ✓ic/%' 0-7- 2 7_ PNprFR'rS/DLNinis[,pwvr.RUd ."� OPFR4TOR/MAN.IGER ❑ 61HXR/1l:1H0R1!l:DAGexr❑ If.4PPut'.r �T it tau rhe BILU(Y: PARri Proof of aulharhatinn to sign Is required AUTHORIZATION TO RFI T111i EASF INFORMATION; Whrn Applicable. I, the owner or operator orthe property bested at the ino,e arts address, hereby IIN �orlwC0UN the Tel of any and all results, geotechnical data andior mvirunmetaVsile aisA'Wn m infonrutlion to INC ,itis )OAQL9N CLRINTY HNVIRONSn'N'I'AL HEALTH DFPARTmLNr as soon aS it is available and SI the SamC Illnerit�5 provided to me or my representative. I„ TYPE OF SERWA REQUESTED: ) A O1 n r� I,, •di COMMENTS: f <:� electronic n,. ACCEPTUD BY; AniawoTo: GehaneFa im Date Survlcc Completed ([t already completed); Foo Amount: 468 Amount Payment Type /lip.) - Invoice 0 EHD 4&oz025 a meat 147413355 REVISED 1197f2D.T3 payment EmKoYEE s: 6213 EMPLOYle it: 8788 5MMECooE: Check 0 10?? DATE 7-29-22 DATE 7-29-22 61I PIE 1601 Payment Date SR FORM (Ootdan ace) 160 Arri J (r{1r�� fLDL.rr ie, ltiq,�IUC c`K IfSILLloo AWAFS3❑ FACWn iIAME i SITE AI?ORES3 0r 0A�o bf.. �fS33(o NAME a HOME Or HAII.JNO AlICgE55 Ili Olf/waM hon Site Addreas) CM Swal N STArr 17 ZJP fir^ CyJ 3 �CG' / ( 2r'g) (�cyo/- �•. APN s � LAPD USE APPL"Tioa e PNOW 82 ( _ ) DOS D"TIMT LOCAnoa Coca CONTRACTOR /SERVICE REQUESTOR REOUESToa,( . n4W � I , ! O CNacK Ht3aL[N Aoorraat BUSIraE3 wA.te /40vE EYr. 401,. o/, d �_ t. ;toy7- HouE or MAA -mo ADDRESS FAX Cm " 1 . 7q cf STATE A ZIP X533 BI_I.LINC ACKNOW! DGEM N'r: 1, the unders.{limed property or business owner, operator or authorized agent or tame, acl:nowk-dge that all site an&or project specific FNVIRONAIEN'fAL HFACrH DFPAIpTdLNr hourly charges associmed with this project or activity will be billed to roe or my business as identified on this form. I also cenilk [hat I have prcpwrd this application and that the work to be performed will be done in accordance with all AN JOA LIN S COUNTY Ordinance Under, .Standards S, and FEDERAL la/ws. ��,, APPLICANT'S SIGNATU—R/E; /�+ ✓ic/%' 0-7- 2 7_ PNprFR'rS/DLNinis[,pwvr.RUd ."� OPFR4TOR/MAN.IGER ❑ 61HXR/1l:1H0R1!l:DAGexr❑ If.4PPut'.r �T it tau rhe BILU(Y: PARri Proof of aulharhatinn to sign Is required AUTHORIZATION TO RFI T111i EASF INFORMATION; Whrn Applicable. I, the owner or operator orthe property bested at the ino,e arts address, hereby IIN �orlwC0UN the Tel of any and all results, geotechnical data andior mvirunmetaVsile aisA'Wn m infonrutlion to INC ,itis )OAQL9N CLRINTY HNVIRONSn'N'I'AL HEALTH DFPARTmLNr as soon aS it is available and SI the SamC Illnerit�5 provided to me or my representative. I„ TYPE OF SERWA REQUESTED: ) A O1 n r� I,, •di COMMENTS: f <:� electronic n,. ACCEPTUD BY; AniawoTo: GehaneFa im Date Survlcc Completed ([t already completed); Foo Amount: 468 Amount Payment Type /lip.) - Invoice 0 EHD 4&oz025 a meat 147413355 REVISED 1197f2D.T3 payment EmKoYEE s: 6213 EMPLOYle it: 8788 5MMECooE: Check 0 10?? DATE 7-29-22 DATE 7-29-22 61I PIE 1601 Payment Date SR FORM (Ootdan ace) 160