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SAN JOAQUIN COUNTY ENVIRONmrzNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly - FACILITY ID # 81MVICE REQUEST III <br /> OVML R f OPERATOR <br /> •+ l / CW-CK It BILLING AOE43 <br /> ( V <br /> FACILITY NAME [1 �L C <br /> &TEA00 as LTi �Z' ( 51&C,k 7X•Al <br /> 9 1U 4ffT �i �s <br /> _ zt C040 r <br /> HovEorMAtmAnwsss (If DW%rantfmmSiteAddressl <br /> Billin Mailing 219Q A1elidian Park Blvd , ate <br /> c" Concord STATE t_ A LP <br /> PNoMe N1 En• APN N LANn Us! APrLv'c,%i 10N r <br /> (9251446-6806 1 ?0 <br /> Pteare #2 <br /> fm 13oS rxa cr� I.ar.ATiaN Coca <br /> (209) 992 9253 NONSENSE <br /> COh'1'i ACTOR / SERVICE REQUESTOR <br /> RE4UEaToR <br /> �•� � a!��� ��� ( �.� CHECK if@ILLtESr9tr2mm ® <br /> BuNmEss NAME <br /> „ Pr�eN _ <br /> AJn EAU <br /> Home of MAna�p �4 � � � - - - - - FAx <br /> C4TV rr * l STATE c✓'r Zu* e `;-7'#'r. 7 <br /> BILLING ACKNOWLEDGEMENT: It the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledga that all alta unwor projad spaa8o EwvlRowmcNtAt Hmiii OcwTMEroy hourly ciiargos associated with Ihts ptotecl or <br /> activity well be billed to me or my business as Identified an this form. <br /> 1 also ccrtrfy that I have prepared this application and that jpr,06rk to be performed will Ire done in aec:atdanca with all Sm JcanauiN <br /> COUNTY Ordnance CodPal Shxtdards, 3ATI! and F <br /> APPLJCANrS SIGNATURE: GATE : 101 '12122 <br /> PAOPEA rY l BUSMESS OVYWER 13 GYMATOrt r MANAGER l7 OTmm AuTWF=eD Arpteror tp <br /> 12 <br /> fl AMrCANT is not the &Il t°.A= proof of authoriradon to sign is re Ired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of Itm property localed at the above <br /> situ address , heretry autharve Ihu roleaaa of any and sA (esults, ge olechnical data andlor envmAirnen4aUs4te assemsmenl ! nfofineGon <br /> to the SAN JOAOUIN COUNTY ENMR04MENTAL HMTN OEPART►IFJrr as soon as It is avadabre and at the same fine if is provided to me or <br /> my representative. <br /> TYPE OF $FRIflC# REdI1ESTED; ' C- ' <br /> CgeeryeNrs: - - <br /> ; I41II . <br /> ACCT_PTED HY : - - EMPLoyee Il: ()ATF: <br /> AaseaNeD TO; EmpiLoYce #: We:SSSSSSI <br /> - - <br /> Date Servlco Completed lir abwdy tampaated) : 9rA ff Cope : PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check * Received By : <br /> EHU 49-tl2•tl25 ,SR FORM (Gallen Rcd) <br /> 4'+ e 7eD8 <br />