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w <br />08/L9/2002 12:45 4640138 ENVIRONMENTAL HEAT–H PAGE- '01 <br />6A.N J OAQULN A0114TY E1VV1R0iNMJ6K1•A.1, REA1;k111*Ait'1-D1bN T <br />SERVICE REQUEST <br />Type of Business or Property <br />CONTRACTOR <br />FA L TY ID'# <br />SERVICE REQUEST # <br />COMMENTS: <br />::':.. <br />00312 <br />OWNER I OPERATOR' <br />Cf_ECK it <br />r <br />BILLING ADDREJ] <br />FACILITY NAME i <br />U 1 <br />TH S Rvi ON •_ <br />SITEADDRESS 0' �]Q6 <br />v x/StlrJeet <br />I Lum <br />PU LIGHEA <br />HEAIjH (1�VISiON <br />t <br />FNVIRONMFN�AL <br />Numb9r <br />UiCr <br />Name <br />DATE: lr <br />/>,SSIGNED TO.. <br />".e. <br />HOME or MAILING ADDRESS (If Differant from Site Address) <br />Stroet Nvmbor <br />P I. la.. <br />pt Nom4 <br />CITY <br />Payment Type <br />STATE: ,ZIP <br />PHONE #1 T <br />APH 11 <br />LAwo Uss APPLICAT106: 0 <br />PHONE #2 Err. <br />Z3OS [iISTRICT''rs` : +1 ' ''x ; LocaTkSFi C'b�l `a t ' <br />�? <br />- 75?.. ,,ra. :7,yti.�, .r�g,_�t ';,';.t: ,%' Pr <br />�✓' <br />1 <br />_ <br />i.T.. t.. ..�„n :.7r. "!�" =`J'.:r...r�:.r. t:`'r <br />CONTRAC'T'OR / SERVICE REQUESTOP. <br />REQUESTOR CHECK If BILLING ADDREsS <br />- <br />BUSINESS NAM — P I N # <br />2: o <br />HOME or MA UNG ADDRESS FAX # <br />CITYe) , _ R i�l STATE L/Z 0 yo Vj� <br />ep- . <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or bc..siness owner, operator or author, .ed agent of same, . <br />acknowledge that all site and/or project specific ENVIRONMENTAL HFALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to we 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 SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, SMkiT and FERE ws. <br />AP1'1.1CANT'S SIGNATURE: DATE. <br />PROPERTY/ 13USiNes5 OvuNrm ❑ OPERATOR/ MANAGER ❑ OT AuTi;C1RiZ8D AGE ` <br />IfAPPLIt ANT is not theSttLINf'tf'AR7T;proofof authorization to sin is reyurre rttc <br />AUT1101 K T10N TO RELEASE INFOI2.MATION: When applicable, I, the owner or operator of the property located at the <br />above site addiress, hereby authorize the release of any and all results, geotechttical data and/or envirorimental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTmzNT 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:USTf <br />W <br />COMMENTS: <br />SEP <br />TH S Rvi ON •_ <br />PU LIGHEA <br />HEAIjH (1�VISiON <br />FNVIRONMFN�AL <br />APFRONt£O BY:. <br />UiCr <br />EMPLOYEE M -y <br />DATE: lr <br />/>,SSIGNED TO.. <br />".e. <br />LMPLOYVE <br />P I. la.. <br />e� Amount:. 7 <br />-�1 payment Date`% <br />Amount Pald ( 1 •.�. <br />Payment Type <br />Invoice # `'. <br />Check # •' '�•. <br />Receivod By:' <br />EHO 48-01-025 L SERVICE REQUESTeCORM <br />REVISED 6-5-M <br />