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01/29/2003 08:58 916646 RHL, DESIGN PAGE 02 <br /> 01/28/2003 10:43 4640138 ENVIRONMENTAL HEA1q PAGE 02 <br /> SAN JVAQUIN COUNKY),':NYIRQNN11L:iV');ALRUALTH D8PARTMENT <br /> SERVICE REQUEST <br /> 'IYpe of Business or Property FACIL"M 0 SERVICE REQUEST I <br /> &V3a5 <br /> OWNER I OPMATOR ' <br /> '�t,loC.pQ�ltt.t..i S. 'S CxEc�ltlo�u.n�FtDORE'S"rs <br /> FS � %& —_->44 <br /> � <br /> SITE AMR>S5114 gfWM15F <br /> Hoot£or MAIuNQ AODR= (tr bltterant from Site Address) <br /> Slreel Number Nome <br /> CRT STATE ZIP <br /> PHONEAl . EXT. APN If Lana UNMAUCAYMo <br /> PHoae12 EM aoS aun:Icr )m Coop <br /> CONTRACTOR I SERVICE RE TOR <br /> R5RUEiFron ; G?rEt trilI�uNo l►oaaEss L..1 <br /> Bu=ESS AAME i PHMEN, fxt. <br /> NOME or MAl1. a' vaREs ` FAX I <br /> fci! ) =c (oi <br /> CrrC- <br /> STATE C– 70P �I� <br /> 1111r1,1k AQCNOWLmGCM>3NT: 1, dw undwsigned'proprrty or basinms owner, operator or au burizctl Agcttat of sonic, <br /> acknowledge Hint all site and/or project specific ENVntONMt1NTALHEALm7i I)I~PARTwNT'llourly oh;%W asap WI.al with this project ar <br /> activity will be billed to nzc or mr bwinm as idcntiFicd on this form. <br /> I also Certify Hutt,)have prepared=RATPR1MMAVXk <br /> e work to bo performed will 1qc dont in aeeordancc with all SAN JQAc LM4 <br /> CoUNW Ordinwice Godes,Stancaws, <br /> APPLIC,ANTIS SIGNATURLriDATE: _1 ?R�Ct'� _ <br /> )�tzolr>stit7f/IiUStpttris OwrteRO BTj=Atrrttovx={1,vv= <br /> UAPPt tCANr is nal Elie gl"48� C P=proof vfaulfwrizWon to rigR rx ragrcirad Tit <br /> AY]7 TORYx•F1330-LV—R.CIX1A0=8M622QN:WhOn applicable,T.the owner ot.opuntor of the property located at.(Ila <br /> above site address, bcraby ottthorize the rtleasc of any And all insults, geotechnical data andlor enviroameritaUsite amassment , <br /> information to the SAN JOAQUIN COUNTY 8; 1110NMENTAL MALTH DEPARTMPNT as soon as it i5 available and'at the same time it i5 <br /> provided to mG or-my representative <br /> TYPE OF$01VICE REWESTED: <br /> Co1lt rtts: . RECEIVED <br /> JAN 2 9 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES' <br /> "AlRONNENTAI-Ht'^!TH DMS' <br /> APFRovEU sy: <br /> A=r.KED'TQ' <r1APLOYEE#: D11SIe �---�— <br /> [)ato Sorvi"Completed (It already con plated}: SFAVICEcom �R PI E.- <br /> Fee <br /> 1=ee Amount; Amount Paid "! Paymunk Date, <br /> Paymo+nt Type • invaica 1k I Check ll13 PO 91816) Rerelved By: <br /> EHD 4"tdlt b ( SERVICE REl M1 T FORM'. <br /> REVtEED66-02. , <br />