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-�--- SF9?V1P.F RF(Jt1EST '-VO'� EH0061 SR revised 07/10196 I� Type of Business or Property FACILITY ID # PHONE#FA SERV/ EQU f lJ *BILLING OWNER/ OPERATOR CITY STATE �.. ZIP PARTY I y uYra ❑ FACILITY NAME PAYMENT DEG 18 1998 SAN SITE ADDRESS ENVIHO UEIUC HEALTH MENTAL HEALTH D V 5101 INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: SVM Number Duwd." ^ 1I ��•••lllJ\ MName � t Type Suite Mailing Address (If Different from Site Address) �� n I n „ ^ �,� C c7 (b DATE: CITY STATE ZIP PHONE#1 EXT. APN# v l7 LAND USE APPLICATION# PHONE #2 BOS DISTRICT LOCATION CODE Invoice # Chec # CONTRACTOR I SERVICE REQUESTOR REOUESTOR BILLING PARTY❑ d BUSINESS NAME�` f/� PHONE#FA MAILING ADDRESS I 7- FA%# I CITY STATE �.. ZIP BILLING ACKNOWLEDGEMENT: 1, 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, ST E d FEDE—��(�(�,/'� APPLICANT SIGNATURE:] 6Gy DATE: PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑— G IfAPPUCANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: when applicable, I, 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 environmentai/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and att the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: . �— COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER ❑ PAYMENT DEG 18 1998 SAN ENVIHO UEIUC HEALTH MENTAL HEALTH D V 5101 INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: APPROVED BY: ^ 1I ��•••lllJ\ EMPLOYEE#: � t DATE: la ASSN)NEDTO: _ �� n I n „ ^ �,� EMPLOYEE#: (b DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount:� v l7 Amount Paid Payment Date i Payment Type Invoice # Chec # Received By: