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Aa;. 1'i. 2.111 9:2'AM San 1oaquia C.'Ucty fio.2202 ) <br />SAN JOA( L ! COUNTY E14VII20N'VMNTAT. REAI.TIi r ARTNIFNT <br />SERVICE REQUEST <br />Typo of Business or Property <br />CHECK Npyai-INCAoone_s <br />FACILITY ID # <br />SERVICE REQUEST 4 <br />HOME c"A GAOORE <br />�J %f <br />_—_— <br />CITY <br />fA%1�J <br />33 <br />37ATE <br />T _ /� _ — — <br />SIf, oa (v 3a qo <br />OWNER/ OPERATOR <br />T� <br />i'ry <br />CHECK if BILLING ADDRESSE] <br />FACLITYHAME <br />/Q C <br />SITEr/,+OOnRE55 <br />6 <br />_ <br />L1,?S-1 <br />_.. <br />L/r �P'a���� <br />elf <br />, abeerNmbir <br />EMPLOYEE M: rl[ <br />s % <br />HONE Or MAILING ADCliE55 (It Dilforeni tram Site Address) <br />f <br />Elate Servide Completed (ii—ilro-Skip eompiend). <br />SERYId CODE! <br />CITY <br />PI <br />STATE ZIP <br />PHONE01 <br />I i <br />agT• i APN <br />LAND Use APPLiCATIONt <br />I <br />PHONE02 <br />I ! <br />E"r <br />Invoice i <br />BOS OraTMCT LOCAnoNCOOIL <br />CONTRACTOR / SERVICE REQI;ESTOR <br />REGuE$roR /� <br />tJiL %/r/lay� <br />CHECK Npyai-INCAoone_s <br />BUSINESS NAME <br />'oD %s <br />( _— <br />PH I <br />(i <br />HOME c"A GAOORE <br />�J %f <br />_—_— <br />CITY <br />fA%1�J <br />33 <br />37ATE <br />T _ /� _ — — <br />— <br />BILLING ACIGNUWLy-DGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all Site and/or project speclfrC ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated witb this project <br />or activity will b- billed to me or my business as identified on this form. <br />I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQLTN <br />COUNTY Ordfnanda Coder, 5ranrtnr&. STATE and FEDERAL laws. / <br />APPLICANT'SSIGNATI1RE f� / <br />PRowtif'rY/ BUsrnass OWNSILEO UPakATOA IMANACEk 2 0*1'H1a An'fN)ALx;O ACIAT 13_ <br />IfAPP1Jl:aNT is not the. 'IMOP.I127ti. foffritrheriZONun 7o sign is required Titre <br />ATH(ORIZATION TO 1R61.EA5B INFOXVATION: When applicable, 1, the owner or operator of the property located at the <br />above site address; hereby authorize the release of any and all results, geotwhnical data antUor enviromnnrtaUsite assessment <br />in&trmation to the SAN JOAQVIN COUNTY FNVIR0N6ffiNTA1 HE.nLTtt DEP.ARTTLENT' as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERviCERE00Ea'TED: <br />'""JA20 <br />ITO <br />Coaaarm <br />pUG 12 2411 <br />L y,H ioAQU MEffliu- <br />�,RTMENI <br />`fON„p <br />ACCEPTED BY: <br />T� <br />ENPLDYek ii: / <br />�• <br />BATE: O r a <br />f/ <br />A5510NED To: <br />EMPLOYEE M: rl[ <br />DATE: <br />f <br />Elate Servide Completed (ii—ilro-Skip eompiend). <br />SERYId CODE! <br />PI <br />b <br />Foe Amount: �a�, <br />Amount Paid <br />f -0 ()Payment Date <br />.Payment Type ✓ <br />Invoice i <br />Check aF (o� <br />Received By: <br />EHO 45-02-025 <br />REVISED 11117/2003 <br />SR FORM (Golden Rodd <br />