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1 2009 <br /> ENVIRONMENT HEALTTi—c�N <br /> JOAQUINCOUNTY ENVIRONMENTAL HEALTHDEPARTMtNT <br /> PERMIT/SERVICES SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> ? 205`753 y <br /> OWNER/OPERATOR ,CHECK IfB o0 C1 <br /> FACILITY NAME I oD I <br /> SITE AD Ess l 6r�IL <br /> Swot Nu ber OI2 me <br /> HO Of MAILINGADDRESS (if Different from>Ito Address) , <br /> 5 nt NumCMr nl �� <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LANG USE APPLICATION <br /> PHONE 2 Car. SOS DISTRICT LOCATIpN CODE <br /> ( 1 / <br /> CONTRACTOR./SERVICE REQUESTOR <br /> FEQUT7CHECKif sO BLNA <br /> BUSINESS NAME / <br /> HOME r AILI ADDR SS <br /> CITY �ol^�n V� $7ATE �f�},�irZIP <br /> Is J LlN , A JCNOW DGE T: 1, tlic undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific CuNViRONMENTAL Hrv�LTH DEPARTMENT hourly charges associated With this prtbect <br /> or activity will be hilted to me 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 he done in accordance with all SAN JOACIIIIN <br /> COUNTY Ordinance Codes,Standards,STAT ld FEDERAL laws. <br /> APKICANT'S SIGNATURE; I y`rte DA fr�j: S-zg-oq <br /> 1°ROI'RRTv/RU'JIN:ss OwNER0 OPRRAI'UR/A'.IANAGBR L—I. O711ERit.UTFTORIT.aD AGENT' \f• / I ,- <br /> 1f.ArrGtrnNT Isnot the l3(j,�L.tra Pilon'proof njauthorization to sign is required ittc VV// <br /> T�RELEA5E INFORMATION: When applicable, I,the owner or operator of the property located ai the <br /> t 0 a ereby authorize the release of any and all results,Hgcotcchnical data and/or environmental0A,MVhr�rt�ek`�gq- <br /> Do fo .TOAQUIN COTJNTY ENVIRONMENTAL'HEA.LTN DEPARTMENT as 500n as it is available and at t1 rata Cl�rpl) <br /> V or my representative. n 1�C <br /> TYPE OF SERVICE REQUESTED: /2><C f-r E-•A--L7-71 A o d ae-.p yaL e�� C-P EZ —JUN 11 20)9 <br /> COMMENTS: Rgluc '�^ l2tlkb�1 mai/t �IfEI Govv6r LLQ/ VfT,6 PS�-WAul-o( SANJOAOUINCO NTY <br /> EN IHONM NT <br /> S+Wq� f1kPo ou Jq)M OR 1.JAe_ <br /> Acr,EPTED 9Y: p LC VEr 44- E.V"c,2E tt: 0 3 z-/ DATE: (Q ((/C)9 <br /> ASSIGNED To: P"P—P4 EMPLOYEE#: Z(.3 DATE: �( Oq <br /> Date Service Completed {?f already completed): SERVICE CODE: <br /> Fee Amount: 0 Amount Paid �V� — Payment Date \tloq <br /> PaymentTypeCInvoice# eClt — Received By: J\f — <br /> EHD 48-02-025 SR FORM(Golden!Rod) <br /> REVISED 1111712003 <br />