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SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE3IOR J j+ <br />;tA.n 1 :�^1 eeugedearaaiAmims <br />BusmEss NAME Hew-, Tet /9Fck. tee is I <br />PtroxE? r'S 3 P-0 <br />HOME Or MA GADDRESS (F j-( afy,CfC l egrr Dr. 13(_4.9 2S I Fall <br />( 1 <br />CITY r_ . / _ _ SKATE /A i,P A Po its <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />aclmowledge that all site and/or project specific ENVIRONMENTAL HFALTN DAPART Ofr hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this ap r tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Coder. Smerdardt,ATE and FFDm , laws. _ <br />APPLICANT'S SIGNATU�RrIL X DAre: O ?� <br />PRorEaTY/BusmL�OWNERA OrncaTDnfmf can❑ DTIaRAUrHOaRlDAcutr❑ <br />1f'APPLIGNr it not the BluJNQ PAQn'. proof ofanDmriaulon to Sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L. the owner or operator of the property located at the <br />above site address, hereby authorize the micas: of any and all results, geotechnical data and/or environmemaUste assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF hRNCEREWRT®: � Plfin <br />2ev,eW 1 i�cfiz�a-fZ__!a T� <br />cmmvns: Pan RevitW & <br />pieafe Frey: ( G�mMlsrfir t' lfrrnprr Li+t Q <br />d:mon® II/o alc{ItZfeCr. Carn <br />ACCEPTED BY: Cu t/'(, CS I EMPLOYEES: DAIS <br />AssicREDTD: U,^ "AVE S I EWLOYEE* DAIS: <br />Date Service Completed(if aheady comptamd); Samoscom: .523 PIE: %(DV/ <br />Fee Amount 64 t D� Amount Pai 60 �� Payment Date / ?� <br />Payment Type I Inhroicai cnecka /6;�6z7IS/77 Feee&dB': <br />EHD4MM25 <br />REVISED 11/172003 <br />/o36%U✓1.S SRFORM (GatlenROO <br />