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SERVICE REQUEST Type of Business or Property _[7 FACILfTY ID # SERVICE REQUEST # OWNERIOPERATOR lii�(�.,^ �� _ �� �l BILLING PARTY FACILITY NAME )VA' i ! AUG 2 7 1998 �� SITE AD qE5 //A Street Numb. Dirxtion j�/I"-r��"/� W7V� (F'(fI�J SK! Strati-Nams'I Type Suitat Mailing Address (If Different from Site Address) DATE: & (1 i ASSIGNED TO: CDrS G O 1 STA ZIP ` 14- PHONE#1 W. (2-0 7 d APN# LAND USE APPLICATION# PHONE #Z a* Amount Paid � 234 DO BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REGUESTOR BAT BUSINESS NAME PHONE# E*T PAYMENt d36 ��''`` MAILING ADDRESS— AUG 2 7 1998 FAX# SAN JOAQuiN ENVIgONMENTA LHS HEAINSPECTORS SIGNATURE: E I VS CONTRACTORS SIGNATURE: CITY STATE ZIP of 20 A 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 to me or my business as identified 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 laws. �a� APPLICANT SIGNANRE: —DATE: e6' —z -P-47 PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER U OTHER AUTHORIZED AGENT e-EF200 ITAParcalrisnotfheBcuNc PARrv. proofofaudraizadon M sign is tMired Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 emironmentadsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same lime it is provided to me or my representative. TYPE OF SERVICE REQUESTED: C J COMMENTS: PAYMENt �Ff'itll Itt-. AUG 2 7 1998 SAN JOAQuiN ENVIgONMENTA LHS HEAINSPECTORS SIGNATURE: E I VS CONTRACTORS SIGNATURE: APPROVED BY: EMPLOYEE #: DATE: & (1 i ASSIGNED TO: t EMPLOYEE #: © DATE: zA Date Service Completed (N already completed): SERVICE CODE: o P 1 E:.Z Fee Amount: 7c_ Amount Paid � 234 DO Payment Date g�� / 8 Payment Type ✓ Invoice # Check # Received By: