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Type of Business or Property <br />FACILITY ID # `yV`v <br />l <br />�PRyE,Z zoc7- Lgi 7-3 BILLING PARTY <br />SERVICE REQUEST # <br />-V -e = <br />r <br />PHONE # Ext. <br />� ZS <br />OWNER I OPERATOR <br />BILLING PARTY 0 <br />FACILITY NAME <br />MAILING ADDRESS <br />SfrEADDRESS ` 1i.�4TEJZ L-662� <br />LL4 J/ <br />>3 Strvst Number efrection SVM Name <br />Mailing Address (If Different from Site Address) <br />TYPE Sulh f <br />CRY <br />IS -r4(, �cTa ti <br />STATE ZIP <br />G ✓� <br />PHONE#1 UT. <br />7 L r <br />` <br />AP N# <br />LANG USE APPLICATION # <br />PHONE #2 EXT. <br />BOS,DISTRICT <br />LOCATION CODE' <br />REQUESTOR <br />CAQ-t— t,v <br />_I <br />�niCE2so�! sl'Z <br />l <br />�PRyE,Z zoc7- Lgi 7-3 BILLING PARTY <br />BUSINESS NAME <br />L C <br />v r L -6_f <br />PHONE # Ext. <br />5>` Yy4l-/7�3v <br />MAILING ADDRESS <br />1c v <br />�Ar2r\ v� <br />FAX # <br />LIqu-i73-s— <br />CRY I—i2 t= s•ti U <br />STATE Gra Zip 9 3 -7 2 <br />bli-LINli AUKNUVVLEDGEMENT; 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 DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certity 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. 4. <br />APPLICANT SIGNATURE: C w - / J G� DATE: <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ASic 2V i C-� % tL A/ <br />If Aaar r Nr is not Hie Bn. M PMrY. proof of authorizatlon to sign is required Title <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 environmentaVsite assessment information to the SAN JOAQUIN 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: <br />6 <br />COMMENTS: ` <br />. L J Iv' �� 7 � tj �, T VE p2v 6i e YIA PAYM EN-( <br />RECEIVED <br />INSPECTORS SIGNATURE: <br />APPROVED BY:. <br />ASSIGND <br />/Yj}; n <br />Date Service Completed (if already completed): <br />Fee Amount: (0-15 <br />Payment Type Ul� !, Invoice 4 <br />Amount Paid <br />CONTRACTOR'S SIGN, <br />EMPLOYEE #: ob D <br />EMPLOYEE #: <br />�t r <br />Check # <br />FEB 0 7 2001 <br />bAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />NVIRONMENTAL HEALTH DIVISION <br />r I DATE: <br />DATE. l/ <br />SERVICE CODE: I C <br />Payment Date <br />A <br />P ! E:2—ZA <br />0 'l D 1 <br />Received Bv:`--;'. C <br />