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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# r/ r,6)0 C.' y SERVICE REQUEST# <br /> « Zz3 -19r 7� �/zocf -I- q <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> FACIIITY NAME r <br /> SITE ADDRESS OY.,,.1, Q <br /> CA, p-33`. <br /> ll 1 �Hum6•r Direction 11' �(A„t Sn*tj1,1 Type Sul',•! <br /> Mailing Address (If Different from Site Addressi <br /> CITY STATE TTX Z1P <br /> PHONE#1 W. APN# LAND USE APPLICATION# <br /> ( - 6 <br /> PHONE#2 aT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR Q - BILLNG PARTY C3(lJn e ,i,' e Je- ' e <br /> BUSINESS NAME PHONE# <br /> ✓IG v Z <br /> MAILING ADDRESS FAx# <br /> ticE p' <br /> 6y _r- _ Iy.0� HCG LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project sFedfic <br /> PUBLIC HEALTH SERvicEs ENvIRCNNENTAL HEALTH DivisiON hourly Charges associated with this project or activity will be bided 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 JCAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE <br /> v PROPERTY I SUSINESS OWNER C OPERATOR/NMAGFR ❑ OTHER AUTHOR¢EO AGENT ❑ <br /> If APPGGWr is not the Bwn <br /> O Pu 7v.proof of authorization to sign Is roqui vd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property kmcated at the above site address,hereby authorize the release of <br /> any and ad results,geotechnical data and/or ervironmentallsite assessment information to the SAN JOAouIN COUNTY PUBLIC 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 /> L TYPE OF SERVICE REQUESTED: <br /> COMMENTS: F,EC F IV F--'LD <br /> MAR 2 4 2003 <br /> SAN JOAOUIN COUNTY <br /> PL'GLIC HE,4LiiI;ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: �( �( <br /> APPROVED BY: ESIPLOY�f , Oy� DATE' 63 . V <br /> ASSIGNED TO: ( J., ��� EmPLOYEE#: Q Y DATE: C'-- P— <br /> Date Service Completed (if already completed): SERV)CECODE: P/E: 03 C's <br /> Fee Amount �Z(L f C'C I Amount Paid �.�� _ Payment Date 3 Z 6 <br /> Payment Type # Check# Received By: <br /> �- Invoice � 9 <br />