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51 vAA -716 c�z d- 3Ms <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 <br /> 2 SERVICE ST <br /> OWNER <br /> # <br /> OWNER I OPERATOR BIL NG PARTY O <br /> BILL CA-'NLEP4 Ott [31- — 'b$4 TE(LLOO root, WA-m7 CAfL WA-914 LLC <br /> FACILITY NAME <br /> lAlAZr—-MLoo Str. ELL. <br /> SITEADDRESS E W A TT E R L 0 0 2 , <br /> 3 I Stwl Number Otrectian Ww Name <br /> TrP� suh I <br /> Mailing Address (If Different from Site Address) <br /> S.A, �^E <br /> CITY STATE ZIP <br /> PHONE#'t EXT. APN# LAND USE APPLICATION# <br /> (Z c-0 o131 — 304 084 - /oo - 3� <br /> PHONE#2 BOS.DtsrTacT LOCATION CODE:. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BUNG PARTY' <br /> �Mlcwa�� U/aL-'otc <br /> BUSINESS N"E PHONE# fzr. <br /> MAILING ADORESS FAX# <br /> . 0 . Tao / 0Z5— 911: 3'4-3— !( � L <br /> CITY W S -r , AcrL4� r,,t, C <br /> STATE C, ZIP 9 S 6 Q ( I <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly charges associated with this projector activitywill be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application an Ihat 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: 7"/ / / iJ <br /> PROPERTY I BUSINESS OWNER O OPERATOR/MANAGER O OTHER AUTHORIZED AGENT C 4 nl T rZ <br /> Il Aver cwr iz not ft Bump Proof of authorizatfon to sfpn Is required 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 environmentallsile assessment information to the SAN JOAmIN 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 /> TYPE OF SERVICE REQUESTED: 'T7` 1Z L V, E VJ <br /> COMMENTS: PAYMENT YME `T. <br /> RRC')` IVC—E) <br /> APR 7 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL, <br /> HEALTH DEPARTMENT <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE q& "t DATE: _Q <br /> ASSIGNEDTO: ',rI � �' EMPLOYEE#: lIILYY��77 DATE: <br /> Date Service Completed (if already completed): SERVICECODE: P I E: a <br /> Fee Amount: ( (f OD Amount Paid v Payment Date A( 71696 D6 ✓► <br /> Payment Type Invoice#' Check# Received By: / <br />