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SERVICE REQUEST EHOO61SR revised 09/04/98 Type of Business or Properpi FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR /- M /AJ s BILLING PARTY FACILITY NAME SITE ADDRESS Z Z ``/ �4'-21A/Q0Q . Street Number -T(Q Direction Street Name Type Suite# Mailing Address (If Different from Site Address) CRY E 7C L0/✓ STAT ?� ZIP S 1� PHONE#1 Ix-r. APN# LAND USE APPLICATION# Z4 r z /49S 3 PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTOR Jo A/ / ^ s 'V 4 C BILLING PARTY❑ BUSINESS NAME PHONE# ET. QuAtt i CoAJi7zVL 1615PEc -f--27-49 0 MAILING ADDRESS FAX# ` Z Sr �/ZA LZ) CRY �JQ 1) T ,V STATE n ZIP 2 f / BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific 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. I also certify 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,ST and FED laws. /d--27- 9f� APPLICANT SIGNATURE: DATE: PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title 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 any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it Is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: S6` COMMENTS ❑ SPECIAL CONDRION(S)O�OFF-APPROVAL El ` OTHER ❑ OCT 2 7 1998 SAV Plieuc HEALTr, ENVIRVNSi:,FVICES -- - -- -- FAENr�� IrEf _ _.--------.......................- _— INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: APPROVED BY: EMPLOYEE#: (/^ DATE: ASSIGNED TO: D V.e\- EMPLOYEE#: W DATE: Date Service Completed (if already ompl ed): SERVICE cnpF: PIE: Z O Fee Amount: Amount Paid . Payment Date �0 7 Payment Type Invoice# Check S 75 Received By: