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i <br /> 0'-- SERYfCE REQUES0 <br /> T <br /> type of Business or Property FACILITY IQ# SERVICE REQUEST <br /> pS t 0 gt4rtA L. ZAat, 9 S <br /> OWNER I OPERATOR <br /> I3twxG Fa2zIY d <br /> 1. M,4 Nur ATR !C A CO <br /> PACIM NME <br /> SrfEARORyE,55 <br /> ` SYrsr N�r7fbw U4.mon L� su..e eam. 7yo. su+t.s <br /> Mailing Address (If Differe t 4 om Site Address) <br /> Cay. <br /> � <br /> I A VATE <br /> 11 F'� z1P 4 0xOx #1 , „ APNif LAND USE APPLICATION 9 <br /> PIHaxS#z Exr SOS Dlsrwcr Loc lTION COUE <br /> fl CONTRACTOR!SERWE REOUESTOR <br /> REauEsroR 'D <br /> BUSINESS 1fAilE PliOXE# _ <br /> MALuxG Aouusa <br /> FAX <br /> {I lv��—zip <br /> STATE eLA ZIP <br /> d <br /> BILLING ACKNOWLEDGEMENT- I, the undersigned property or businass owner,operator or authorized agent of same,aclmawledge that ad 3r7e andlar pntact spedk <br /> Puauc HEALTH SawV Es ENViRCrwuaAL HEALTH DNi5M hourly charges associated wish Gxs project or auh*wi0 be bled to ma or my business as idenWied on this k)m <br /> I a(tlm chat I have prepared th" a Gcation and rk to be perfomsed W be dose in a=danca with ati SAN JOAQM COta rY ftmar=Codas.Some,STATE and <br /> F [.1aws. 7 <br /> Af PUGANT SIGNATURC DA77=: r// 0/ <br /> P OPERTY!BUSINESStJYPNER QPERATORIAAANAGER OTHER AUTHOR=AGENT <br /> YA"IrANTisrrer pM0fofmdwibPdarfaskWi$ Tlrle <br /> AUTHORV-ATIONTORELEASEJNFORNIABON:When AppkAbte,L the ewnw or operator of dw pmp u ty located at the above sits addreos,hereby authorize the r8lease or <br /> My and as results,geate0niml data am9or errvironaaentalfsits assessment obs atlon to the Sm iatiwv Cotwm Aueuc mMTH SEEznM Bw*whKjorrma.HEAL-.H GwvoN as soon <br /> as it Is available and at Um same time 4 is provided>b crab Of my mpn mata4M <br /> T4PE OF SERVICE REQUESTED: <br /> O/L A�3 crt E V E{,V <br /> COMUE=. <br /> PAYMENT <br /> RECEIVED <br /> JUL 172001 <br /> SAN JOAC,�UIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HiFALTHi DIVI3I0N <br /> 121 PECTOR'5 SIGNATT)RE CONTRACTOR'S SMRATURE• <br /> APPROYE:98Y: _ +J F IPL�Y�#: DAM <br /> ASSIGtiEpTo: aYEE#. '� 77 DATA:: <br /> Date Service Completed i{tf already completed): SE;wMCOGE: C-- - P/'E- <br /> mom <br /> Z�G I <br /> Fee Amount~ ff {i ^� � Amount Paid 3 / <br /> I �q Paymcnt Date <br /> Aaymeitt'fypt: lTlvoice# Check# j Received By: <br />