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• SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# - SERVICE REQUEST <br /> ,yam l �' S 3 <br /> BILLING PARTY❑ <br /> OWNER OPERATOR <br /> PaGILtn'NAME <br /> SITE ADDRESS t <br /> Z l D� �� atrM NwMfr of an <br /> L / Lnneama r Sunt <br /> Mailing Address (It Different from Site Address) <br /> STATE ZIP <br /> CITY <br /> APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> PHONE#2 BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REOUESTOR <br /> BILLING PAR <br /> RE^hIF.sTOR <br /> f,1�) , z^i. vS %h <br /> PHONE X <br /> BUSINESS NAME _ _ r �" oS V I <br /> iSl�firJ L', f>�C FAx# <br /> MAILING ADDRESS <br /> L c�i0 ZIP <br /> CITY <br /> STATE <br /> 1-'Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business ovmer, operator or authored agent of same. acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assooated with this project or activity will be billed to me or my business as ideudbed on Nis form. <br /> I also certify that I have prepared ' application and that the work to be performed will be done in acoomance with all SAN JOAOUm COUNTY Ordinance Codes. Standards.STATE and <br /> FECERAL laws. <br /> APPLICANT SIGNANRE: �� ��7T� / DATE:_ <br /> PROPERTY I BUSINESS OWNER ❑ OPERATORI MANAGER ❑ OTHER AUTHORIZED AGENT ❑ tills <br /> IfAPPlKANr k not do Rr 1 mPiny,prop/or aurbofcadan to sign o fpuhad <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the owner or operator of the property lasted at the above site address,hereby authorize the release of <br /> any and all results,geolerimiCal darn andlor envhronmemaysite assessment Into nation to the SAN JOAGUIN 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 represemative. <br /> TYPE OF SERVICE REQUESTED: �. �y_� ni -t -- — – - <br /> _�\�� l�.W ___ _ <br /> COMMENTS: f1cjR14APDrTIoV4., INf-oRMATrOpq %W61UEjrM MR. Twij T/f staW�Eg,, 4uEs7� 0 <br /> P&V <br /> MAR 2 21999 <br /> soca.aG;�:ltllhv ch�uwTv <br /> PLIBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNANRE: <br /> CONTRACTOR'S SIGNATURE: ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY:� ( EmptoYEEX: btu DATE: 3 a� <br /> ASSIGNED T0: I EMPLOYEE:: DATE: <br /> Q- SERVICE CODE: 5 1 PIE;- r <br /> Date Service Co feted (If already completed): <br /> Fee Amount: Amount Paid /SLP, I Payment Dale 3'a yhg <br /> Payment Type w I Invoice 9 Check 4 Received By: (�/J�- <br />