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SERVICE REOUFST <br />Type of Business or Property <br />FACILITY ID # (� i <br />r 1 \ iS l <br />BUSINESS NAME L� <br />SERVICE ES #(�` <br />31 `�� ✓Z0 <br />OWNER OPERATOR <br />PHONE # Ext. <br />�5�- Y (1q- <br />1-MAILING <br />BILLING PARTY <br />FACILITY NAME <br />FAx # <br />s-sy-yvy�,7.3.� <br />$READDRESS � � <br />If <br />��\�CJ' �•�`'' l <br />Trw <br />sunt. R <br />Mailing Address (If Different from Site Address) <br />CITY ( <br />STATE LP <br />PHONE #1 E;cr <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />BOS:DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />Lf'+22 <br />BILLING PARTY 0 <br />BUSINESS NAME L� <br />5�2� cEs <br />PHONE # Ext. <br />�5�- Y (1q- <br />1-MAILING <br />MAILINGADDRESS <br />FAx # <br />s-sy-yvy�,7.3.� <br />CrTY r` 2� S r <br />STATE CA Z1P <j-? -7 Z <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION hourly charges associated with this project or activity will be billed to me or my business as identified on this torn. <br />I also certify that I have prep this application and that the <br />FEDERAL laws. �—`"r✓t y� <br />�APPUCANT SIGNATURE: / <br />to be performed will be done in acoordanoe with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />3-Z4_ o I <br />PROPERTY BUSINESS OMER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT -4—).5&-1-W < < %F C <br />If APK. mr is not the Bwyg PAfrrr Proof of aulborizadon to sign is mquirsd rifle <br />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 <br />any and all results, geotechnical data and/or envilonmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon <br />as it is available and at the same time it is provided to me or my representative. <br />