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• 0 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> . av s Ft4 0up13 93 52oo25922 <br /> OWNER OPERATOR BILLING PARTY <br /> FACILITY NAME ��I� <br /> AN ECA 4,t UdK <br /> SREADDRESSSS`/�r]I, N Hf �._ <br /> V 1 y St"I Numbr etre .n 5 N�m1 iYV� S�Ib� <br /> Mailing Address (If Different from Site Address) <br /> CITY <br /> INIPWIEC A SC F• 9 S3-S <br /> P(HHONNEE#1 raT• APN# LAND USE APPLICATION <br /> sso <br /> PHONE#2 Ea. BOS-0ISTRICT - - LOCATIONCOOE' - <br /> ,•ap <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY <br /> G B <br /> BUSINESS NAME PHONE# [AT. <br /> 791f - otoL <br /> MAILING ADDRESS Fax# <br /> �o � 9N-0) I2 <br /> CITY STATE LP C)5-e <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that an site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity win 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. <br /> APPLICANT SIGNATURE: DATE: Ll- <br /> PROPERTY/BUSINESS <br /> -/_PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑_ <br /> Il Acaucwrisnofrhe B.UmcPunY proolofsurhedrsdon to sign is rvqukvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 environmentalisile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same lime itis provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: .J <br /> PAYMEN_.. <br /> RECEIVED <br /> APR 11 X001 <br /> SAN JOAQUIN COUNTti <br /> HEATH <br /> ENVIRONLH <br /> MENTAILHEAL VICES pVSION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. "'Vl/1 EMPLOYEE#: [f DATE: <br /> ASSIGNEDTO: EMPLOYEE#: - -7 �7� DATE: L4 <br /> / t � ' <br /> Dale Service Completed (if already c pleted): U SERVICECODE: . 1 P/E: 22nd. <br /> Fee Amount: a,(Q I Amount Paid 7 1 Payment Date v <br /> Payment Type C hC tC Invoice#' Check# <br /> j Received By: <br />