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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> JJt091-s <br /> FACILITY NAME <br /> SITE AOORESS <br /> ,DSa..Nom. TY" suits C <br /> Mailing Address (If Different from Site Address) <br /> Cm STATE Zm <br /> Pte,#1 b ✓l' Err APN# LAND USE APPUCATION# <br /> PHa�Ne�#2 �,q 0 nDISTRICT LOCATION CODE <br /> "� I CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR I <br /> BILLING PARTY t3' <br /> UAwGR I.-TY PAC)v l L 3be V-1P,tM <br /> BUSINESS NAME PON# <br /> MAILING ADDRESS FAX# <br /> I�Dl t-0 fur <br /> CITY S-1 <br /> r+ �T STATE (�[� I ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andfor 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 farm. <br /> I also certify that I have prepared this appl' ton and at the work to be perfomhed will be done in accordance with at SAN JOAoUM COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OMER ❑ OPERATOR)MANAGER ❑ OTHFAAUDtORIZED AGENT ❑ <br /> ItAtYt iS mrthe BEI MPA ..proof ofwdwintion to sign is Mukd Till& <br /> AUTHORIZATION TO.RELEASE INFORMATION:When applicable,I,the amer or operator of the property located at the above site address,hereby authorize the release of <br /> any and all insults,geotechnical data anhllor envimnmentaltsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DPAsION as soon <br /> as t is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> �- YK <br /> COMMENTS: <br /> MAR2Q2i <br /> SAN JUAUUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> .t ENVIRONMENTAL HEALTH DIVISION <br /> // cc� W� 1 <br /> INSPECTOR'S SIGNATURE: t /✓r•-(1-O C,cz�'—`— CONTRACTOWS SIGNATURE: <br /> APPROVED BY: EyPLOYESt ATE: 5—,2-0 -00— O _ 0 <br /> ASSIGNED T0: EMPLOYEE#: DATE: 3— vv C/ <br /> � ZU ' 7 <br /> Date Service Completed (if already completed): SERVICECODE: tr PIE. 30 -: <br /> Fee Amount -� 3 y , �U Amount Paid Payment Date 3 —a0 — (gyp <br /> Payment Type Invoice# Check 9 LI5 01 Received By: <br />