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SANJOA COUNTY)ENVIRONMENTAL HEALTH DEPARTMENT 1 <br /> SERVICE REQUEST ° 1 <br /> Type of business or Property FACILITY 1D# SERVICE REQUEST# <br /> of <br /> OWNER I OPERATOR <br /> I;ll S <br /> FACIuTY NAME �01M$P � P(?-o?eR-V 4 <br /> SITEADDRESS �'2,ppi.+ C. (AWf1iE - 51n 4;7-115 <br /> xI Cod <br /> street Number Direct' Street N <br /> HOME or MAILINGADORFSS (if Different from Site Address) 11 1q1:1 E, Cr*03N L <br /> CITY STArEC'1p1,, zip c{ri WC <br /> T, APN LARD Use APPLICATION aY <br /> PNONEIIi a,go-o tJNw(w4cI] �' -04'—t3r727 s <br /> PHONE 82 EXT. BOS DISTRICT LOCATION COOS <br /> lloii <br /> .-- CONTRACTOR! SERVICE REQ JESTOR n <br /> REQUESTOr2 ,AV /} CHECK if By-uNC_ADDREa � ■ <br /> •' +�I l 1-' C'� PRONE# Ex*. <br /> BUSINESsNAME L-tJl: 0p� 6Cp EN�ItitICDNWIE/�'1�t- 34pq�0$ S' <br /> FAx# <br /> HOs»E or MAILING ADDRESS gr, i? ) ;�-� s <br /> STATE A ZIP 9 ri j4'c� <br /> CITY L,p rj l <br /> JULLING ACENOVULEIIGEMEI 11: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvfRONM>.NTALREALTti DEt'Att.TMbbrT hourly charges associated Aiith this project or <br /> activity will be billcd to me or my buslams as identificd on this forth. <br /> I also certify that I have prepared this application and that thr tiroark to be performed will be done in accordance with all SAN JOA,QUIN <br /> COUNTY Ordinance Codes,Standards,STATE a IpEnFRAL laws. . <br /> APPLICANT'S SIGNATURE: DATE: <br /> xoyt erx 1 Bussrness Owlvxr�0� p"ATORI lv ANAGxn El 4 rrmrA AuTrroXnizasa AC.XN-r 13 rifle <br /> if ApPLIC.tNT is not t e,8 tN�,proof of autfiurization to.sign is required <br /> Ail'A' ORI TI(]N O AS E ,A. O : when,applicable,I�a hniGal data owner or pandJor t;nerator ofv onmez>he property located <br /> assessment <br /> above site Address, hereby authorize the release of any and all results, g <br /> information to the SAN JOAQuTN COUNTY ENv[RONMEh1TALHEALTm DEPARTMENT as Soon as it is available and at the same time it i5 <br /> provided to me or my representative. PP+YME <br /> TYPE OFSFRVICEREQUESTED: <br /> COMMENTS C-o"17?t-,`f r/J74"T-t 0'1SANerJ4 <br /> r r` QAQISI � tstSTf <br /> it l ryvw, DEPAR �N7 <br />[ ACcEPTED BY: <br /> EMPLOYEE#: D 3-z-I <br /> DATE: �` <br /> EMPLOYHE q0'[-S DATE: i d <br /> A <br /> ssIGN ED, O: -�'-�S I o �LA-t--OS <br /> ce Completed (if already completed): <br /> SERACE CODE. 31,5' PtE: 003 <br /> U, <br /> Amount Paid a3 L7, Payment Date f ! o <br /> ype Invoice# Check# p <br /> ,sceivgd ay: <br /> SR FORM(Gol(len Rod) <br /> EHD 48-02-025 <br /> 14 REVISED 1711712003 <br />