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SAN JOAQUl OUNTY ENVIRONMENTAL HEALTI*PARTMENT <br />- SERVICE REQUEST <br />Type of l3iasmess.or Properfy <br />FACILITY (D # SERVICE REQUEST # <br />,S73 - <br />QHVNDi2/OPERATOR <br />cc <br />CHECK if BILLING•ADDRE.SS CI <br />NAME' <br />" � � StLE ADDRESS <br />X21Char n <br />1�d o <br />9 �i <br />m �� <br />Street Number . Direction <br />Street Name <br />city Zip Code <br />`� HWVIE or MAILING ADDRESS (If Different from Site Address) <br />r <br />- • <br />Street Number <br />Street Name <br />4i17Y- <br />STATE Zip <br />�/{" <br />.: k PHONE #i Err' APN # <br />.992. <br />LAND USE APPLICATION #. <br />PtfoNE#2 Exr• <br />BOS DISTRICT <br />LOCATION CODE <br />F - CO, NTR AC'T-R/,q Ta'RVT('1F <br />IRT+ (3TTF S7'nR <br />ay REQUESTOR CHECK ifBILLING ADDRESS <br />- <br />' �T151N1�5S.NA1V1E `LUL E <br />� ' • r � ` PHONE #) � ms• <br />2c"�4 <br />- H�7NiE DC MAILING ADDRESS <br />7 <br />FAX # <br />h - -. ;- <br />2WPM MXF1 <br />Kx- <br />CITY STATE ZIP <br />RZT;LLLtTO ACKNkWLEDGE1kIENT: I, the undersigned'property or business owner, operator or authorized agent of same, <br />acknowledge that all:site aIidh project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />achuity willbe. billed_#o me oi-nny:business..as identif ed_on-this form <br />also certify that.I have prepared this application and that the work to be perfozmed will be done in accordance with all SAN JoAQu>rr <br />O0I7IvMT ' z7rd nanca Codes, Standgrds,,-STATE and. EMERAL laws. <br />AI'PLICANT'SSIGNATUirE( �� DATE: I1 (jjL3 <br />T <br />�RO$ERTX/$�SOWNERL':i OPERATOR [MANAGER 0. OTHER AT1T owzEDAGENT <br />f fiPPLIGriNT.is not.the,.B)EUNGPAR TY proof of authorization to sign is required Tate <br />A THORI AT OI�i TO EL`EASE 1('N£'ORl!'I:ATIQN -When applicablaJ, filie owner or_ope ator of ttze property located at the <br />-- =—_ <br />-- located - - <br />above : ite adtl�ress� hereby aut iorize ,are ease of any 'and all results;. geotechnical ;data and/or .environmentallsitc assessment <br />iritizmation.o tht �:4N Jt�r�gt7JN CUrrTY-ENVutONMENTAI HEALTH DEPARTMENT -as soon as it is available and at the same.tnne itis <br />proved"eta to me or xny-representaftve — -- <br />-+ --- _-- <br />PE'DFFS�ERVICE-REQUESTED <br />E'OMMENT�- <br />"7.2013- <br />MC_ <br />OTY <br />F <br />SAN pA�O <br />tflO � RT'(�1fEN'F <br />pL <br />►-1EAi'TN <br />JAGDEPTEDBY EMPLOYEE.#: DATE: <br />l <br />SIiQLr10 { " LF # . DATE: <br />NIPLOYE <br />bra 'tib s <br />aiteersfCe GOrnpleted (Ifalreadycompleted) SERVICE CODE: PI E:.nl2 <br />FeebAmottnt u` �mount'Pald 1 ..... Payment Date <br />3S_oc� 3 <br />' <br />f'aayment Type__ Invoice # Check # ¢¢ Ret eived By <br />U <br />• 1 r { N : { A .i^I 3 ^r._'_ 4 f { r• y 1 Ii. t' '_'r f . 1 <br />• � � � A a �' 1 A �' � , r { � � y .i'k • -- `�' • ` ! � � � � � . 1 1 s � Y , + . L y 4 `, e . xM'. a � e 4 . + '.. � ' ` « r 0 L . , <br />