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'18-4/2002 12:45 4640138 ENVIRONMENTAL H*AR:lM PAGE 01 <br />H <br />�► 6A.NJVA(2U�lNANTYENVIRUNmEtV'�A.l,k1.1t;Al-;TklkNT <br />SERVI {' IRROTTF.fiT <br />Type of Business or Property <br />ACII i fY ID'# <br />' <br />SERVICE REQUEST # <br />.3 . �. <br />. <br />OQ 3-i <br />OWNER / OPERATOR <br />— <br />CHECK If BILLING AD_ DREgg 13 <br />FACERY NAME <br />- <br />n <br />SITEADDRESS D <br />y�ly`l <br />J I "` <br />I vL trC-~ t� <br />h����12� <br />Scree Number <br />Direction <br />Name <br />try <br />C <br />HOME or MAILING ADDRESS (If Different frons Site Address) <br />Street Numi>er <br />an, <br />CITY <br />STATE zP <br />PHONE 91 a'R <br />APN # <br />LANo UsAr'PucnnoN # <br />.( v <br />PHONE #2 Fxr <br />.y <br />CONTRACTOR / SERVICE R.EQUESTOR <br />REQUESTOR _ jj�� <br />,L(!:>,r (Z_4n)E CHECK If BILLINGADDRFSS0 <br />$USINECS nl _ 1 �M ^, ^� PNOiE 70 2 T Ezr. <br />1`� CJ <br />HOME or MAILING ADDRESS 'AY If <br />CCCY �/ STATE zip <br />BILLING ACKNOV YLEDGEMENT: `Z 4kc"uu ieuigni-.d property or business owner, operator or authorized agent of saint, . <br />deknowiedge that all site and/or project specific ENVUtQ,N,AENTALHEALTW DEPARTMENT hourly charges associated with tins project or <br />`activity'wUl be billed to me of m; business as iddntifl! xidtl>is form <br />I also certify that I have preyarrd this application and that th^� to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Sta.:ndords, ST E and FEDEi A' `t /5. <br />A.PPLICANT'$ SIGNATURE I p DATE: 4 - <br />PROPERTY/ 13usj,,qes. <br />OWtiEI2C', OPERATOR/ MANAGER 41TIIER AUTHORIZED AGENT <br />IfAPPLIC-tNT s not th e f LLLfdg PAR 7.7 proof of authorization to sign i4 require Tate <br />AiJTIIOMZ_,TTON TO ...ELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, heresy authorize the release of any and all results, gcotechaical data and/or cnvi,ronmental/s:tc assessment <br />infomnation to the SAN JO -',.QUIN COUNTY ENVIRONMENTAL HEALTEi DEPARTMENT as soon as it is available and at the same tir:,c it is <br />provided to me or my representative: <br />TYPE OF SERVICE REQUESTED: VT eleI 0 <br />COMMENTS: <br />/0 0 RECEIVE <br />SEP m zo�2 <br />` p ©LIC HPN E LTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />-APPROVED BY EMPLO.EE Vii: DATE: <br />�1 ZZ Z y q <br />-ASSIGN6 To: �', _' , EMPLOYEE # DATE: ,, ;q.c b' • : ` .• <br />Fee Amount: Amount Patd�-7� �-... payment Data <br />Payment Type <br />Invoice .# Check # Recoivad By <br />25 <br />✓� <br />EV ISED SED 6-S�t�2 <br />R ` SERVICE P•_QUEST C©RM <br />REV <br />