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Sa\ ,IOAQUIN' COCYTV E\t'IRON'N[E\TAL HEAI.TA DFPAR"1 Alf---N I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# I SERVICE REQUEST# <br /> O-OXOt,t''Otc; rx lYbl11 SB11 SPIN 8 (0 ai$ <br /> OWNER/OPE. RATOR /. /1 p <br /> 1 1 I /� r C�� cc4o GHECK{(BILLING ADDRESS <br /> FACT NAME <br /> 0'+0Lr'& na V � •7L <br /> 1T7 <br /> $R �},� <br /> EADDRESS3 S 70 ` QR, 'RdaOt -rra 9.53a� <br /> S1ree1 Numbar DlRauen S r Nrme C-J no Cade <br /> HOME or MALING ADDRESS (if Different from Site AddresAL r0 etlt Cti ovep "Road <br /> r75 Sveel Hamper su"I Name <br /> CITY Tra $ ATE ZlP�r3 yin <br /> rn <br /> PHONE#1 - Exn APN# LAND USE APPLICATION# <br /> (.2IA) $140-G7Gc <br /> PHONE z2 E"- SOS DISTRICT LOCATION CGDE <br /> ,�,oq, 7'17-7777 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK it BILLING ADDRESS[] <br /> BUSINESS NAME PHONE EaT. <br /> HOME Or MAILING ADDRESS Fut# <br /> I ) <br /> CITY STATE ZIP <br /> BILLING ACK�O"'LEDGE,%lE.\'f: 1. the uodctsigned property or business owner. operator or authorized agent of same, <br /> acknot ledge that all site and or project specific ENvlRU\r%IENTAL HLALTH DEP%RT\1F\T hourly charge, aswaated with this piGieci <br /> or Ucltvitry will be billed 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 perlormed will be done in accordance with all SAN JO.AQUN <br /> Cot'\'n' Ordinonce Codes.Standards,STATE and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: c>:le��q DATE: of �� �GQ3 <br /> PROPER]',I BCSI\ESS OIVNER❑ OFERAT'OR/:MANAGt:R fIQ OTHERALTHORIZEDAGrm 13 <br /> Ii,IPPt.LANIisnortheBILLANGPaRTF.proofOJuurlydriadourosiguisreyuired Titre <br /> AUTHORIZATION' TO RELEASE INFORMATION: When applicable. I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results. geotechnical data and or emironmenta� 'itc assessment <br /> information to the S AN JOAQUHN Cot-NTN' El viRON\1F\TAl HFALTH D£PAkTH?NT as Soon as it is available and at tMC time it is <br /> provided to mr or my representative. R <br /> TYPE OF SERVICE REQuESTE-D: <br /> COMMENTS: SqN✓0 IV <br /> y ?0?3 <br /> H� Tti4)�ALM M NT( Y <br /> FA/T <br /> ACCEPTEO BY: K L EMPLOYEE#: 45'89 DATE' ' - 3 -d 3 <br /> ASSIGNED TO: L� ^`tri c � EMPLOYEE#: y t 9 DATE: 1 - :S--ZS <br /> Date Service Completed (if already completed): SERVICE CODE: V b P)E: `b C) <br /> Fee Amount: \'S b — Amount Paid 1 j>� — Payment Date V -'L- 2-S <br /> Payment Type CC Invoice# Check# I'S EYE& I Received By: <br /> EHOS ('I SR FORAd(Golden Rod) <br /> REVISEDED 1111 11]1712003 _I <br />