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01/13/2003 13:30 46401"18 ENVIRONMENTAL HEALTH PAGE 02 <br /> A- .) <br /> SAN JOAQt,tN COUNTY LNVIRONMENTAL HLAL i d DEPAR"I W NT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID I SERVICE:REQUEST If <br /> OWNER <br /> ��•-( CHECKII BILUNO ADORE59 <br /> FACIUTY'r AME <br /> Is. 1� � � <br /> SITE ADDRESS <br /> 1 P' L1 <br /> Ir vmba 01 ellTn '--�— Ince Name CII I <br /> HOME Or MAILING ADDRESS (If oirferent from SUR Address) et <br /> Slreel Number Slreel Name <br /> CITY STATE ZIP <br /> PHONE 111 . EXT. APN V LAND USE APPLICATION# <br /> 1 <br /> T- <br /> PHDNE02 EaT• BOS DISTAIC7LOCATION CODE <br /> i I <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> PSS CHECKIf BILLING ADORES91:1 <br /> BUSINESS NAM -�� .J PHONE N E"T• <br /> Tfc�� T74-�jo <br /> HOME MAILIN�,.ApDDRESS FAX M <br /> LSo,c S a 8 4 ► <br /> CIV6 - ?3 <br /> TY C C� \ STAT" ZIP �-Zc <br /> 1111JAN`GG ACKNOWLEDGEMENT: I, (he undcrsigned property or business owner, operator or arrthorizcd agent of same, <br /> acknowledge that all site and/or project specific ENVINONMEWAL HEALTH DCPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that,I have prepared this application and that the work to be performe ill be done in accordance with all SAN 1oAQurN <br /> COUNTY Ordinance Codes,Standa,dr, TB and Ftp ttAL la <br /> PPLICANT'S SIGNATURE: DATE: <br /> PROF tSRTY/BUSINUS OwNrR❑ Orr•,RATOR/MANA ❑ OT11r.R AuTIlORIZCU AcaNT❑ <br /> If APPLICANT is 1101 file BIIIJNG PARTI,proof of authori2;atdon t0,fign 4T regrrlred Tirlr <br /> dUTHORIZ,ATiON TO RE11,13ASE INFQRMAT10N: When applialble, I,the owner or operator of the property located at die <br /> above site addrens, hereby authorize the release of any And all results. Seotechnical data and/or environmental/site, assessment <br /> information to the SAN 10AQUIN COUNTY I;NVIRONMCNTAL HEALTH DEFARTNIeNT as soon as it is available and at (he, same lime it is <br /> provided to me or my rcprescn(ative, <br /> TYPE OF SERVICE REQUESTED; j ?/c t F�l7 CEwE <br /> COMMENTS: <br /> �O L <br /> SP ENC"a Nt PRjM t� , <br /> ' NEA4�N O� <br /> APPROVED BY: EMPLOYEE IU: 7 DATE. <br /> ASSIGNED T0: M L� EMPLOYEE DATE: 13 C� <br /> Date Service Completed (If alreadycomploted): SERVICE CODE: PSE; 3C1� <br /> Fee Amount: �'��/ Amount Paid Payment Data. (( ��/rj3 <br /> Payment Typo i/ Invoice 0 Chock# Recaivod B <br /> EHO 4841.026 SERVICE RCOUCST FO <br /> REVISED 8•G•02 <br />