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1 - r _ SERVICE REQUEST FACILITY IDR SERVICE REQUEST Type of Business or Property 9 s,WNER I OPERATO� � I FACILITY NAME SITE ADDRESS / `�� `> yL eh /�L� rro• 5ui��r / ' 1 umryr 'Olr an Mailing Address (If Different tram Site Add ss) C STATE / ` IP �✓��i C rrr A,, LAND USE APPLICATION APN PHONE 70 U / I LOCATION CODE �cr. BOS DtsTRICT PHONE n2 f CONTRACTOR I SERVICE REQUESTOR BILLING PARTY REQ0F.S10R PHONE _ ter. r� BUSINESS NAME FAx 9 MAIUNG ADDRESS, �- G'' ` STATE ZIP CrrY v,G;s / L ite andlof BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authOr ACJy wfll be billed bbf me or mybusiness las identifiedge that all ed project spm Ic ed on this form ?U6UC HEALTH SERVICES ErrvIAONMENTAL HEALTH OMSION hourly cnarges assocated with M's Protect n I also certify that I have prepared this applicaodn and that the work to be performed wffl be done in ac�niace with all SAN JOACUIN CGl1rITY 0��^ance Codes, Sfandaros.STATE and FEDERAL laws. OATS' APPUCANT SIGNATURE: '' 7Z❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Tit 1 a PROPERTY/BUSINESS OWNER 1Apm r-AmrisnotdvkUt _P-r-y P'9Ol al authoraatlon to sign isnW'vd AUTHORIZATION TO RELEASE INFORMATION•When applicable.I.the owner or operator of the property located H at the above site address,hereby authorize the release of any and all results,geotechnical data and/or envltCnmentaVsite assessment into Marion to the SAN JOAOUIN COUNTY Pusuc HEALTH SERVICES ENVIRONMENTAL E:LTH DIVI$iDN as soon as it is available and at the same time his provided to me or My representative. TYPE OF SERVICE REQUESTED: — -- _ " 7, �r COMMENTS: Jar - 'Uc4' CONTRACTOR'S SIGIIATURE: INSPECTOR'S SIGNATURE: / I ,, DATE: �j " `N EMPLOYEE N• S L .APPROVED 9Y: /—� / C DATE: C�/✓ EMPLOYEE R: �� gala, ASSIGNED T0: � SERVICE CODE: Date Service Completed (If already Completed): I gee amount: �` — I Amount Paid �j3� I Payment Oate f l Payment Type I Invoice x Check �� Received By: