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OEUN J k)AQUily U1N'1'Y LIN VHWjN1VIL+INTAL ktLAl;l' FAKfMEN 1'
<br /> SERVICE REQUEST
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<br /> Type of Business or Property r r r,.'.;;,r
<br /> YP 1• I F CIL ID'# va •I,, _ .
<br /> Its W1 " 3 F}� 7; . 3ERVICERE(�U
<br /> G 4S 5779-77 0 A l `,:.'X ►.t' y" 4 � �ij; :Jr r�?. t H,: '` +?' •�� ', < f�;��'; ,4, t4,b( '
<br /> OWNER OPERATOR/ + .Y,.'r I•" ,nlre`lf�T' 'f'1 r�'!; M )1 ''}{•,i n� :Stti�' I" � q
<br /> 7- . ❑ •._�'`• .+, r
<br /> 6-5 /�•� 00 As T 10R0,0 a L.r 1 CHECK If SILLING ADDRESS
<br /> FACILITT NAME n ( 6 6 O L D
<br /> WE ADDRESS Q
<br /> d u 1156-
<br /> Zln Code
<br /> /+T74kb P . . 9533'0
<br /> Stree(NumMr S e t. _ ..e.
<br /> CI
<br /> HOME or MAILING ADDRESS (If Different from Site Address) -
<br /> street Number 3 reel Name
<br /> CITY STATE ZIP _.. . .... ...
<br /> PHONE A1E)ffTAPN#. LAND USE APPLICATION#
<br /> (aoq) x(83-
<br /> PHONE# Exr. D•-. I�.T y.• �Y ,{ .. =:
<br /> L'gcgtiiit�'C8o
<br /> CONTRACTOR/ SERVICE REQUESTOR t,
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<br /> REQUESTOR
<br /> L�O IZ I FRE5I-1-0 a rK.
<br /> CHECK If BILLINg ADDREss
<br /> BUSINESS NAME
<br /> TFq-, "T- ev V 's VS,�n� S PHONE En.
<br /> HOME or MAILING ADDRESS FAX#
<br /> 37-?'3 I_QY0146, VIS ,
<br /> CITY me GTV V/2-d 6 V PSTATEzip
<br /> BILLING ACKNOWLEDGEMENT: I, the.undersigned property or business owner,operator or authorized agent'of same,,'rrri;r
<br /> acknowledge that all site and/or project specific ENwtoNMENTAL HEALTH DEPARTMENT hourly charges associated with this prtiject'or
<br /> activity will be billed to me or my business as identified on this form. ct r•.�•'rt: �"{
<br /> I 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 Codes,Standards,STATE and FEDERAL laws. �,^
<br /> APPLICANT'S SIGNATURE: I 7
<br /> DATE:
<br /> PROPERTY/BUsINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT®' l�A 11T✓L� � '
<br /> lf.4ppmcANT is not the BILLING PARTl:proof of authorization to sign is required Tule
<br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable;I,the owner or operator of the property located at the :
<br /> above site address, hereby authorize the release of any and Al results, geotechnical data and/or environmental/site assessment,"'...'.'
<br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTtt DEPARTMENT as soon as,it is available and at the same time it is
<br /> provided to me or my representative.
<br /> TYPE 4f SERVICE REQUESTED:' l?tciaLp C'tc rX rJ6�Z►7Z)/Q GJ/T74 LID Z O. O O i ;ri
<br /> COMMENTS: I L 1''d
<br /> RECEIVED
<br /> 1: `-ti.'�?�'4, 'i ,� ' .,�t;;'i ol:�; klr�bl�! 'a p:fi`iSLivt P;�;�'(�{i.9 •,tib+{ .f 3, -SA
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<br /> �'UN J h1QILIfN C%)l Tom•. = , c ,#� ^t 3„�y,
<br /> �APPit0V1=DB �..:r" .. r•� 41 s' ..1 ! 1 LiF 1.'{,.. !\�y��/r' 1�. r 7,'. V��J
<br /> Y: i^e r . fi ,�iyfl °{, + EMPLO1rE.,.r ci l 6 ?p�F, i kra i ;
<br /> u`' EA#�<. r ! , *' ! DA ��7'ti �r!
<br /> ,•�y.\:fir,,.• R.,IC,•. h.Jt•�+Q..�. v 'b:•\..:�'i,�.•Y :C'+'�•rn.!
<br /> 'ASSIGNED TO , r•�a l t ` I r .kr ; } i •" ,� EMPLOTEE\#.'u ! a i�'a <r,:`1 ?ya..y.
<br /> S ,l c !�Y,.} Ji r y�,t .
<br /> Date'ServlceCote leted Ifaireed com Ieted ' r -,..:'t' •t.'�t '►� / �('+ ERVIGECiODE'
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<br /> Pa entT a �: ,r f ► ,rear �.�
<br /> r Check# IZecelved By: ; `?' r?
<br /> EHD 48-01-025 _ Y.
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<br /> nrnn^I-h SERVICE REQUt7 FORM<+,',;'•'"
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