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�.e SERVICE REQUEST <br />Type f Business or Property <br />)ul�.� 1IyBs�LIw�PARtY <br />BUSINESS NAM' JL I Il Lc4 �((�„))ilV/tt'��'7! �l/�l <br />0 ah in i <br />FACILITY ID # SERVICE REQUEST / <br />ffontl <br />FAX* <br />C TY STATE ( Zip 7'77 6 <br />OYYaER I TDR <br />/ <br />BILLING PAM ❑ <br />FACLLRY NAME <br />COMMENTS: <br />- <br />� <br />.S <br />Cti/l✓d7�lU✓) <br />ser Nunes <br />arseae <br />snetau. <br />SAN aOAOUIN COUNT, <br />PUBUCHENVIRONMENT <br />sw.s <br />MaAing rses VDifferentfromSiteAddm% <br />L HEAL 4 DIRVICVSIO <br />INSPECTOR'$ SIGNATUPW, <br />CONTRACTOR's SMATURE: <br />APPROVED BY: <br />Cm <br />EMPLOY --A: �J <br />DATE: <br />!n <br />V� <br />`' 9j/� <br />( EY/IQ !"�- <br />(,r/�pac <br />O <br />APN# <br />LAND USE APPLICATION# <br />/ <br />PRONE# <br />O an. <br />BOS DIsmicT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />rtEDuesroRL "l fioq <br />)ul�.� 1IyBs�LIw�PARtY <br />BUSINESS NAM' JL I Il Lc4 �((�„))ilV/tt'��'7! �l/�l <br />0 ah in i <br />Fa 3o ye <br />MAILING ADDRESS /_ �h `� <br />((f V D <br />FAX* <br />C TY STATE ( Zip 7'77 6 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorced agent of same, acknowledge that all site ardor project specie <br />PuBuc HEALTH SERvicEs ENVIRONMENTAL HEALTH DNtSION hourly charges associated with this project or activity will be bil to me or my business as idenCBed on this form. <br />I also Deftly that I have prepared this application and that the work to be performed will be done in aavrdance with all SAN JOAwhN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: UATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHEAAUIHORIZED AGENT ❑ <br />MAr+u^ 4r1O(fM8JLLavGPunv. prodofauewkadon to sign is rnqubw Titte <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator at the property located at the above site addmss, hereby author¢e the release of <br />any and all results, geotechnical data angor arwvonmentallsite assessment information to the SAN JOAQUIN COUNTY PUlIW HEALTH SERVICES EWINONMENTAL HEALTH DIVISION as soon <br />as M1 is available and at the same time it's provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: /— / <br />Z <br />/! G' <br />COMMENTS: <br />- <br />PAYMEW <br />RECEIVEr <br />NOV 3 0 1998 <br />SAN aOAOUIN COUNT, <br />PUBUCHENVIRONMENT <br />L HEAL 4 DIRVICVSIO <br />INSPECTOR'$ SIGNATUPW, <br />CONTRACTOR's SMATURE: <br />APPROVED BY: <br />EMPLOY --A: �J <br />DATE: <br />ID <br />CJ <br />ASSIGNED TO: <br />EMPLOYEE : L('J <br />DATE: <br />/ <br />ie <br />Date Service Completed (if already completed): <br />SEWCE CODE: <br />' C <br />'P I L'. d" <br />Fee Amount: <br />Amount Paid -7 ("ate <br />Payment Date <br />Q Z 3 g <br />Payment Typ e, <br />Invoice # <br />Check # / ^ � <br />Record BY• <br />