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k • SERVICE REQUEST <br /> Type of Business Or Property FACILITY ID# SERVICEjtEQU ST <br /> OWNER I OPERATOR BILLING PARTY <br /> F EiG <br /> FACILITY NAME Z�5 L I O <br /> SITEADDRESS <br /> 5Q Leh !rc�ovr�-t3 <br /> Street Number elractlpn Streel Name Type suoap <br /> Mailing Address (If Different from Site Address) <br /> -71 VIES Q V'- <br /> CITY I N'J ST TEr ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (ICY) 7� 735 <br /> PHONE#2 EV. <br /> DISTRICT LOCATNJN CODE <br /> 7 I00 1,0 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME C PHONE# 7 /0-010 Ezr <br /> N) at <br /> MAILING ADDRESS FAX If <br /> VO �I 5D r\ L(l 20 ///9i� <br /> CITY - STATE ZIP G L" <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> 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. <br /> 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 <br /> FEDERAL laws. L-- <br /> — (� <br /> APPUCANT SIGNATURE �p N DATE: C>/- O <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT .STNFF GPoI�I }� <br /> If APPucawrisnoffheftu PAmv.p=(of&nhodzaWn to sign is mquM Title <br /> 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 <br /> any and all results,geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY Puauc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: l/`C� '�.'V ✓ W / <br /> PAYMENT <br /> IRF17,11FIl n <br /> AUG 2 8 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH,SERVIrES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: q '}�. . D _ .01 ., EMPLOYEE � �^ DATE: Z� <br /> ASSIGNEDTO: l /cwt ,I ��T'C EMPLOYEE#: ©a©V DATE: 2 <br /> Date Service Completedd (i`f already completed): OOOSERVICE CGDE: p 3 4J 1 PIE;, <br /> 3 O <br /> Fee Amount (P O Amount Paid Payment Date <br /> Payment Type Invoice# Check#v Received By: <br />