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t 08819/2002 12:45 4640138 ENVIRONMENTAL H H PAGE 01 <br /> 6A.N J OAQUIN t NTY EINVIk�Vi1Mk V'I'A.L k)<1e;A-XII A TME NT <br /> SERVICE REQUEST <br /> Type of Business or Property «::,. '.FACILITY ID'# SERVICE REQUEST <br /> OWNER/OP BATOR <br /> CHECK if BILLING ADDRES$❑ <br /> FAcxm NAME <br /> SITE ADDRESS <br /> Street Number Dlrectlon Name -`•� 'e <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Sirnet Number am <br /> CITY STATE ZIP <br /> PHONE#1 APN 11 LAND USS APPLICATION# <br /> PHoK#2 Ezr. s.:,.;:: �;. <br /> BOS t�IS7RrCT .:,y,.•, LOCATidFt Ct)T)�M1 <br /> "'7t'. •trr.--Ji^i;`,q-.: .( }� - =`J::;`.in�4'ypd`' <br /> 2 = <br /> CONTRACTOR/ SERVICE REQUESTOP. - <br /> REQUESTOR <br /> CNECKIf 81LLING_ADD9ES$11 <br /> Lo ) <br /> BUSINESS NAME-�-� 1 n� Q-� E ` on rn�n3n L c, P # g b - 70 2- 0 <br /> NOME or MAILING ADDRESS n r— FAX#2) P O ^ 6 �r <br /> �2 ?_ <br /> CITY '^n (2a STATE 4 ` I /y <br /> BU,LING ACKNOWLEDGEMENT: I, the'undersigned property or business owner, operator or authorized agent of sarne,. <br /> acknowledge that all site and/or project specific ENviRoNMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be perfortrred will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standards,S7 and F DERAL laws. p <br /> APPLICANT'S SIGNATURE: � DATE. O 2 <br /> PROPERTY/l3usm sS OvNrA❑ OPERATOR/MANAGER ❑ THER AtrrnomzEo AGENX ` <br /> IfAPPUGINT is not the 8W Wg_&RTY,proof of authorization to sign is required Title <br /> AUTI OIZiZA I ION'I O RELEASE INFO ATTON:When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviroamental/site assessment <br /> information to the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DFFARTmp4T as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S , <br /> Commexrs: PA <br /> RECEIVED <br /> SEP a 9 2x02 <br /> SAN JOAQUIN COUNTY <br /> pUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> EMPLOYE NiPtOYE > <br /> EY: : DATE: <br /> ASSIGNED TO. a:• EMPIOY�E#: :.' ='� DATE:.;:;?.-% e`i:'• <br /> pate Setvlce•Completed f already cotnpltitod): SERvlcc t+obl: P fE: :7 <br /> l=ee Amount: . 7-` Amount Paid Payment Datta <br /> •Paymont Type• Invoice#• Check#. Receivad By:' <br /> EHD 48-01-025 SERVICE REQUEST#CORM <br /> REVISED 6-5702. <br />