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OLP. ;` ooeszr <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business <br /> or Property <br /> FACILITY ID a SERVICE REQUEST�e <br /> E40007 <br /> OWNER I OPERATOR r, I �D//PRS CwacK 1/8ki ec Aoo•eu❑ <br /> FACurr NAME QNE�� <br /> SRE ADDRESS L�(J�O t>�w E90�/ . 14 AA Ra/. <br /> e1,.a Nu ., • fl • � <br /> HDPE or MA&wG ADDRESS 111 DANrant from Sita rddr"s) <br /> xd)Ily� CITY STATE may_ Nzw <br /> vv6 ; 5-r q /ma y�+I a.� <br /> a II APN a Who VDE APR2ATpN a <br /> ,as- 57:5.j <br /> PHONE 07 OMTWT LOCATM,N Wpf <br /> CONTRACTOR/ SERVICE RE UESTOR <br /> REOumon 04 D <br /> tNfC /C'N•e '` CxfGf 11&LL:MG AOUIESS❑ <br /> Busess NAPE PHONE <br /> EA <br /> C6,f!' .-A X r1 410360p' E 316-- 356L <br /> HOME or MArard ADOREsskw 4Rors/ Cao i r.T lam✓ '�do.� FAr a 6 3J-a-9 vY <br /> lOm. y�7 yMen STATE gog�.� ZIv �yS� <br /> BILUNG ACKNOWLEOGEMENT 1, the UrdeMogned property w b"twas owner, operator w authorized agent of same. <br /> acknowledge "I all site andlor prlteCt speaft ENVRONAXENTAI HEk,7. OEPXP-%lEN' nonny Charges eSSOC41WO wM lr^ prgect or <br /> activity wil Oe billed to me w my business as identif"on this torr <br /> 1 also certify trot I nave prepared this ap De pertnrin. wIt be dm Wimur one accordance m all SJOAO+LN <br /> CcvN•Y Ororoance Codes. Slandara .- and tna:thew <br /> .E and FELE <br /> APPLICANT'S SIGNATURE: —_•r-Z- ` �• DATE: 6/J��s / J• <br /> 74- <br /> PROPERTY)BUSINESS OWNER OPERATOR I MANAGER 1:1OTheR AU7HORItEO AOENTE�. 17r Or•r.4�C of��a� � <br /> !1 APPL.�um?a not Me&uuyc PufTv,proof of authorization to sign is required rill. <br /> AUTwORIZATION TO RELEASE INFORMATION: Wher. appi4aae, I. me owner or operator of she property iocawd aI the atove <br /> site address. hereby authonae the reisese Of any and all results,geoaecnnlcal data and/or ewronmentaNidd asaesarrrent information <br /> to the SAN JOAQUIN COUNT. ENYIRONMEx A HE.0 Tn DEPARTMENT as soon as a-s aVaaabte and at the same timed Is proV ed to m.. c., <br /> my representative SAY <br /> TYPE OF SERVICE REOUESTED: I �CCE -6 <br /> JUNLaeRxrs: <br /> 01 <br /> $% 1015 <br /> HEV�ROHy0rr," <br /> ACCEPTED BY: EMPLOYE[$: DAT(: <br /> ASSIGNED To: EMPLOYEE V. DAYE- <br /> Date Service Completed (if ady completed): SERVKE Yuo <br /> m: 061 <br /> PIE: O <br /> FM Amount: Amoum Pal /3o.db Payment Date � / 1- <br /> Payment Type M Invoice/ C d A �/o S.�L.J Received By <br /> EHO 48-02 J75 ' 1 y�//-� SR FORM fGrolden Roe; <br /> 07,17108 �`o V na- V y/ /, 1 <br /> ( a09) y68- 3ti1/6 <br />