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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 4 SERVICE REQUEST <br /> - 1�a te- , . o 1- <br /> HElOPERATOR li BILLxIG PARTY <br /> FA. NAME I� ' <br /> Srn�>�AoDR�Eiss �h p <br /> S7eee Humber altnton SIr,K xim. Troy Sint•0 <br /> Mailing Address {If Different from SitefAddress) <br /> CITY � _ STATE Z1P <br /> PHONE 4`1 ryl.ETT• APN# LARD USE APPLICATION# <br /> PHONE#2 `En BOS DISTRICT F <br /> OCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR I BILLING PARTY 0 <br /> 9USINESS NAME PHONe# EXT. <br /> MAILING ADDRESS FAX# <br /> I <br /> CITY II. STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andlor project spetirlc <br /> P')SLIC HEALTH SERvICEs ENvtRoNmENTAL HEALTH OMSION houny charges assocated with Cris project or activity wll be billed to me or my business as identified an this form. <br /> I also certify that I have prepared this a I' tion and that the work to berrfonned will be done in accordance with all SAH JoAauw CwNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. �j /,�.r•�l�/ ray �] <br /> APPLJCANT SIGNATURE:— I �'i // DATE: ` — r� <br /> I. <br /> PRCPERTY I SUStNESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIU-0 AGENT 0 <br /> It APRjcA+rts not V 6xiM PAR pmot of audwmadon ro sign is r"Uk 4 Tills <br /> AUTHORIZATION TO RELEASE INFORM 4TION:When applicable.t.the owner or operator of the property located at the above site address,hereby authonze the release of <br /> any and aft results,geotechnical data andlor enVironmentallsite assessment into motion to the SAN JOAQUIN COUNTY PuSuc HEALTH SERVICES ENVIRONMENTAL HEALTH DMsiON as soon <br /> as it is available and at the same time it is provided to me of my representative. <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: <br /> PAYMENT <br /> APF 2 U 1999 <br /> SAN JOAUIN <br /> ENVfAON C HEA <br /> LTH sERV CEg <br /> ARENTAL HEALTH OIvfSION, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED 9Y: r I CSIPLOYE-r 9: C00 DATE: <br /> [ElMeS,r,ice <br /> TO: II EMPLOYE£#rr: GATE: <br /> Completed {If already completed): l 3 SERMCECODE: aP 1 E: <br /> Fee Amount: � � � I. Amount Paid �$/s� , 0 I Payment Date <br /> Received By: <br /> Payment Type ln+iolce# { Check I /t13 <br /> f <br />