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v SERVICE REQUEST %-g FH0nA19R rpviepd n9/nd/9R Type of Business or Property rz�ral / FACILITY ID # BILLING PARTY SERVICE REQUEST # o/ OWNER/OPERATOR f/ T / BILLING PARTY ❑ FACILITY NAME A 14 SITE ADORES -''^NTlc a /.Nam 446 &1 Type Suila/ Mailing Address (If Different from Site Address) DATE: i APPROVED BY: / CRY EMPLOYEE#: (� TL//14- STATE ZIP \ e4 PHONE#1 �T APN# LAND USE APPLICATION# PHONE#2 BOS DISTRICT Fee Amount: 3 LOCATION CODE CONTRACTOR I SERVICE REQUESTOR REQUESTOR / BILLING PARTY BUSINESS NAME SPECIAL CONDrriom(S) OF APPROVAL ❑ OTHER PHONE -337 Eh. SEP 2 81998 a tri MAILING ADDRESSFAX SAN dOAQUIN COUN(Y PUBLIC HEALTH ;UN RVI ENVIRONMENT cn� I-...... INSPECTOR'S SIGNATURE: # DATE: i APPROVED BY: / 6 EMPLOYEE#: �6 TL//14- CmZ-CJ'o \ e4 STATE /!� ZIP / 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 tha a work to be performed will De done in accordance with II SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA APPLICANT SIGNATOR L DATE:— PROPERTY / BUSINESS ATE:PROPERTY/BUSINESS OWNER ❑ OPERATOR/ UER ❑ OTHER AUTHORIZED AGENT ❑ II APPLICANT Is not the BILLING PARTY. proof of authorization to sign is required P T it la 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 environmental/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: COMMENTS ❑ � / SPECIAL CONDrriom(S) OF APPROVAL ❑ OTHER ❑ ENT pl�t^IFr'rlrr. SEP 2 81998 SAN dOAQUIN COUN(Y PUBLIC HEALTH ;UN RVI ENVIRONMENT cn� I-...... INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: i APPROVED BY: / -J� EMPLOYEE#: �6 DATE: ASSIGNEDTO: EMPLOYEE#: Q DATE: Date Service Com leted (if already completed): SERVICE CODE: S O 3 PIE: Fee Amount: 3 Amount Paid d� Payment Date 2L 19 Payment Type Invoice # Check # Received By: