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SAN JOAQWOUNTY ENvmoNMENTAAL HEALTSEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n n FftQOD.s 13 <br /> U11NER/:OPERATOR <br /> CHECK If$ILLING,ADDRESSL1 <br /> F i <br /> y^t3 unaA'> A'DILITYNAME 'U.L ..C�E•'(''l l'�L KW� 1L <br /> � ac C LV <br /> IT AoDR ss .; Fli l t��'1cXlT I UZ JZ <br /> ti >xa cityZipCode <br /> Street Number Direction Street Name <br /> y. k <br /> y Hagar M ILING ADDRESS (If Different from Site Address) <br /> 4 r ' I 4 Street Number Street Name <br /> 117 �ITY� STATE •n C"PG 1C105 <br /> 4�te NONE#1 Ezr. APN# LAND USE APPLI <br /> CATION#• <br /> l ( <br /> #2 <br /> BOIS DISTRICT LOCATION CODE <br /> — CONTRACTOR/SERVICE !! QUES' OR <br /> rs:;uta 3 ad- `-' .. - <br /> aHECIUESTOR CHECK If BILLING ADDRESS <br /> Exr <br /> " ` ` Bt)SINrS§NAME PHONE <br /> W,1 <br /> ' .. <br /> FAX <br /> I�OMEQrIUTAILINGADDRESS, -6- <br /> � J . <br /> 25 <br /> sk t CITY STATE. Qp <br /> ZIP <br /> ._gITI,INO.ACNC� T�GE1kIENT: I, .the undersigned property or business owner, operator or authorized agent of same, <br /> F aclalowe dge that allsliti4nd/or ot6ject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> G� +� sctralty well be belled to zne or my business.as identified-on-this form • <br /> I,also certify that I have„prepared'this application and that the work to be performed will be done in accordance with all 5Ari JoAQUIN <br /> 11 <br /> 0T-Y.Qrdcnance Codes, tgria ds,:'STATE and FEE)gM laws. <br /> �” ry <br /> APPLICANT'S SIGNATURE 9�Y L1 DATE: <br /> k s <br /> P00, <br /> ROOPERATORI:MANAGER I OTHER AUTHORIZEDAGENT _� L <br /> IfAPPLIGAN not the A&Ln PARTY proof of authorization to sign is required Title <br /> Is <br /> Ai�THURIZATIO' TO`M E . E QRM TION When apphcable;7Lthe:owner or operator of fhe property located at the <br /> _ y— eoteclCA.data an�flor enviromndntaUsite assessment <br /> '� = a�ioe=t:Ile.address here authorize t�Ie reoease of an ani.all results,.g <br /> 4 <br /> _ arn�ation to the SA r JOA U ouN I YT NVIRONMBNTAL HBAI TH DEPARTMENT as soon as It is available and at the same time Ills <br /> �irD#!�de }tb`me or�Iny <br /> re e. <br /> a ypEIIF SERVICEREQUESTEO <br /> — - .- - NT <br /> kw iIYM�4tTS <br /> A: <br /> RECEIVED <br /> S� vr�Y <br /> t <br /> JUL '1 12013 <br /> SAN JOAQUIN COUNTY . <br /> j � .:;1 o <br /> ENVIHOMENTAL <br /> LH <br /> * k ACCUTEDY <br /> 'Z V <br /> DEMPLOYEE M DATE: <br /> '7 l( 3 <br /> .- <br /> EMPLOYEE#C., /t 13 <br /> /��Z <br /> DATE' <br /> ' Dalte S+§rvlce Completed (If already.completed) t`'j Q <br /> i. _ E. <br /> SERVICE CODE• <br /> Amotant Pail] payment Data <br /> ee dmount� `;. !J <br /> =t 'r / <br /> �::kPytnent Tj�p <br /> e Invoice#; Check# 03 Received By: <br />