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SERVICE REQUEST Type of Business or Property FACILITY ID # SES IICCE R E OWNER / OPERATOR CHECK if BILLING ADDRESS E AU6251%n FACILITY NAME eNVIPUBU0 HEALTH SERVICES I SITE ADDRESS INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: �^ S C.—Bv�. / I441IiAtef—yCl 3 Z 4tz;- strssLum99 Direction �/ 1�/- �/y �!' �rl T I 5 'le• HOME or MAILING ADDRESS (If Different from Site Address) ��\_ DATE: EMPLOYEE #: �; CITY STATE ZIP - PHONE #t EMT. l 1 qpN it LANG USE APPLICATION # tib -; Amount Paid PHONE#Z E'T ( ) BOS DISTRICT LOCATION CODE _ CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS 0 BUSINESS NAME PHONE# Ext S too _ s HOME or MAILING ADDRESS FAIL# CITY STATE ZIP BILLING ACKINOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all Site and/or project Specific PUBLIC IfFALFII SERVICES ENVIRONMENTAL HEALTti DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that 1 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 laws. APPLICANT'S SIGNATURE: J DATE: �rio . 7/ .9 PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHERAUTHORIZED AGENT IJfAPPLICTNT is not the BILLING P.IRTr, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: Wlten applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or envirmamental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC 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: I �ZSG1/�-cJ COMMENTS: AY , T RECEIVED y AU6251%n eNVIPUBU0 HEALTH SERVICES MgEA gONMEL HLTH OIVISIO INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED BY: i EMPLOYEE #: DATE: ASSIGNED TO: ', fl 7 t ��\_ DATE: EMPLOYEE #: �; Date Service Completed (If already completed): SERVICE CODE: P I E: 2� Foe Amount: tib -; Amount Paid Payment Date Payment Type Receii. Check # Received By: �.