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L SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # COMMENTS: INSPECTOR'S SIGNATURE: BUSINESS NAME 01771Y OWNER I OPERATOR BILLING PARTY 0 — FACILITY NWIME SITE ADDRESS S DATE: J -63`2 CITY STATE zip /919 Street Numb. Direction Amount Paid �� f Stre.Name ��/(} Type s. Mailing Address (If Different from Site Address) O (/ CIrY STATE zip 52.0(0 PHONE#1 EXT. APN# LAND USE APPLICATION# PHONE #2 EXT BOS DISTRICT LOCATN)N CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR BIWNG PARTY u COMMENTS: INSPECTOR'S SIGNATURE: BUSINESS NAME ivPRO'J"cD BY: C PHONE # aT EMPLOYEE#: (SSI 0 — MAILING ADDRESS FAX# S DATE: J -63`2 CITY STATE zip I P I E: Fee Amount BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed t0 me or my business as identf fled on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL IawS. APPLICANT SIGNATURE: I L�Ct'\ [ � DATE: PROPERTY /BUSINESSC*4ER' OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT e lfAPP mrisrmtdre RauNGPAnrv. Proof ofauthorizadon to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, the owner or operator of the property located at the above she address. hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY Puauc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: (' J COMMENTS: INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: ivPRO'J"cD BY: C EMPLOYEE#: (SSI DATE. ASSIGNED TO: 0S5 h—a^ EMPLOYEE#: 6) DATE: J Date Service Completed (if already completed): SERVICE CODE: I P I E: Fee Amount Amount Paid �� f Payment Date Payment Type L Invoice # Check # (/ Received By: