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e SAN JOAQOCOUNTY ENVIRONMENTAL HEAL'r1-PAR'FMEN'l' <br /> SERVICE REQUEST <br /> Type of Business or property <br /> FACILITY ID# SERVICE REQUEST# <br /> e enSln <br /> �acoo 3b 4. <br /> ts 512001&3 <br /> is 4 <br /> OWNER/OP TOR II CHECK if BILLING ADDRESS❑ <br /> SA INQ OY +t <br /> FACIL <br /> SDEADDRESSL�•I r,�c--'• 5a <br /> � . c cea. <br /> Street NUMNlf Direction Street Name LL a <br /> I1011E IIWukG ADDRESS IN Different fmm Site Address) RQnC tr Cl �neS�1 lJ�t-.t'rj . <br /> attest tleme <br /> OS Street NumMr nz P <br /> S '7 /3at) <br /> Ci �QrK <br /> uxo USE APPucwnox# <br /> PHONE#1 <br /> gco5) <br /> Farr BIDSD�Tp1DT LOCATION CODE <br /> 1a <br /> PNE ffi <br /> l 1 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR r� CHECKNBIWxGADDRE83❑ <br /> cz�ctn& F�CIL�- r`S PHOE# EXT, <br /> BUSINESS E1 i�h 50() <br /> u s i4 l�Ct�O I t N� FAx# <br /> yt�ME or LING ADDR S (fig) 5 <br /> `Zcrj i1c4tone'J �l ted. <br /> SPATEQA- <br /> BILLING <br /> Il_ ZIP <br /> CmNQ�bur ParkLll t U <br /> BIT r Mur•_ ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAi_ HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this loan. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codev,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: '3 <br /> PROPERTY/BUSINESS OWNEE� opERATtRiMANAGCR13 OTHER AUfHORI7.EDAGCNTO <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign iv required Till, <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 results, geotechnical data and/or environmental/site assessment <br /> information to the SAN 10AQLTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 1.� cc L L� (� <br /> TYPE DF S8MCE REQUESTED: J U R U 1 <br /> COMMENTS: RE�NE� <br /> -?J exec. S 4r-) <br /> nl J lx< �4" <br /> SAN JOAOUIN GOON <br /> NMENTAL <br /> /� <br /> ,t �1 �¢ F <br /> AGt:EPfED BY: �L (V�E Its` EMPLOYEE C./ �Zt DATE: `G�7PJ5 <br /> ASSIGNED TO. Lt A7-,4 IJ Y to,-6, EMPLOYEE M e?3" DATE: 3 z y.l t)S <br /> Date Service Completed (U already completed): SERVICECODE: a,Y PI E: 2,3.08 <br /> Fee Amount: )--7e,, GL) Amount Paid t a.7 I- D 0 1 <br /> Payment Date ?� ?.L10 <br /> Payment Type Invoice# Check# 3jqL Received By: <br /> EHD 4"2-025 I^(�(�lII _ �o nRotl <br /> REVISED 111172003 U 11 V "LLL��� <br /> h;AR 9, 2 2005 <br /> ENVIRONMENT HEALTH <br /> prntAlTMrrnnrr� <br />