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s • SERVICE REQUEST • , <br /> vFACILITY ID q SERVICE REQUEST <br /> Type of Business or Property Q('✓ � 3/ <br /> © BILLING PARTY ID <br /> OWNER I OPERATOR <br /> FACILITY IAME xx//� ��.{p II/ /\`�j1�, � <br /> SITE ADDRESS s(.f,�'1'\ J \�V\10Y� _ •"S�SWnNamr Trp. SuiNI <br /> strM Number DeaNan <br /> Mailing Address (If Different from Site AAddressl <br /> CITY STATE ZIP <br /> LAND USE APPLICATION#PHONE,Y'I APN# J <br /> (q L) 72- LOCATN)N CODE <br /> PHONE A2 Err. BOS DISTRICT <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQNFSTOR BILLING PARTY <br /> P <br /> P Pllour:q <br /> BUSINESS NAME -_.—_ .. ._. ___._._._._. -72� <br /> r <br /> MAILING OGRESS FAX>X XPC i �_��� <br /> 1 C 6 0 r� <br /> CRY _ STATE LP DV <br /> 6'f <br /> c^({ m fT v 1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authortzed agent of same, acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENWRONMENTAL HEALTH DNIsION hourly charges associated with this project or activity will be billed to me or my business as identified on this loan. <br /> I also certify[hat 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 <br /> FEDERAL laws. �� (� <br /> APPLICANT SIGNATURE: ( .yC]a tr�J — DATE: K'17`7S <br /> PROPERTY/BUSINESS OWNER 0 OPERATORI MANAGER OIHERAUmORIZEDAGEW ie cofl ULA IIA - <br /> NAPaLcwrlandlMBaler.P.wrr..prop/ofaudorizaeon tuelan lamqubad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property haled at the above site address,hereby authonze the release of <br /> any and all results,geotechnical data ancilor environmentallslte assessment Info motion to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as Iris available and at the same lime II is provided N me or my representative. <br /> TYPE OF SERVICE REQUESTED: ---- — <br /> CGI� ! I <br /> COMMENTS'. r <br /> iry <br /> MAY 17 100 <br /> SAN JOAQI!IN COUNTY <br /> PUBLIC HF1.TH SERVICES <br /> SNVIRCNMEN I%L HPILTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: - ,` EMPLOYEE X: Cc) l DATE: -5 <br /> ASSIGNED TO: t„{��� EMPLOYEE': �j l S� DATE: <br /> Dale Service Completed (it already completed(: SERVICE CODE: �7 U7 J f E: 3 <br /> Fee Amount: � Amount Paid _ 10� Payment Dale �I <br /> Payment Type Invoice 4 Clleck H Received By: <br />