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SERVICE REQUEST 0 FACILITY ID# SERVICE REQUEST#.. Type of Business or Property 'O r BILLING P RTY OWNER I OPERATOR c r— FACILITY NAMEC`,> A SIE ADDRESS —C=`l T fly ` Street Neme pe Suitea O $Vent Number Oittctian Mailing Address (If Different from Site Address) STATE zip CITY PHONE#1 EXTAPN# LAND USE APPLICATION# ( ) PHONE#2 �� BOS DISTRICT LOCATION CODE ONTRACTORI RVICE REQUESTOR BILLING PARTY❑ REQUESTOR PHONE# ' slNEss NAME - u (�!� y� K A FAX# MA G ADORE C� C T CITY S BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that ail site and/or project specific PUBLIC HEALTH SERVICEBit -V— PROPERTY y 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 havework to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. 1 DATE: APPLICANT SIGNATURE: ' l r Q l PROPERTYI BUSINESS OWNER ❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED AG ENT Nc-eTitle IlApatl✓wi is ndihe Bn..u+cPaary Proof of authorization to sign is required 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 environmentallsite 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: DEC 15 1998 PUBLIC SAN OtiUUIN CC, EN V/FONME j AL HEAL? E INSPECTOR'S SIG RE: CONTRACTOR'S SIGNATURE: APPROVED B0 #; i�v EMPLOYEE ASSIGNED TO: - dl v 1` 1� EMPLOYEE#: 0 DATE: 2 r�-I Date Service Completed (if a dy completed. SERVICE CODE: 0— L. Fee Amount: ��, CIO Paid �!`G�.00 Payment Date Payment Type Invoice# Check# L16ff 7 Receive By.