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Type of Business or property SERVICE REQUESTFACILITY ID# <br /> SERVICE REQUEST <br /> OWNER 1.OPERATOR ` <br /> S .PRr� �JJG`j BeLLI:♦G PARrr❑ <br /> FAci rrY NAME <br />► SITEADDRESS <br /> StletHurnbw <br /> WOO xamt ryp. sulto rr <br /> Mailing Address (]f different from Site Addressy � <br /> uti <br /> CITY <br /> STATE ZIP <br /> PHONE 99 rte- APN# d Z <br /> ►7O <br /> � a,� � / LAND USE APPIJCATiOR# <br /> L 6 055 - 210-03/ 2 <br /> PHONE#2 , <br /> acs ntsTxlcT _, <br /> Lot:ATloN CODE a <br /> CONTRACTOR I SERVICE REQUESTOR <br /> Ra:gUESTOR <br /> SUAIG.PARW)g <br />° BUSINESS NAME /� _- <br /> &4m.YR�? /�zz �/1C . PHONE# / E4. <br /> MAILING ADDRESS <br /> STATE ,4 .ZIP �7 B <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project spearn k <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DWION hourly Charges associated wish this projector activity will be billed to me or my business as idenUried on this form. t <br /> I also ce[Vty that I have preZt1hisnd that the work to be o will be done in accordance with all SAN 1aAavIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. 99 <br />' APPGCAHT SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATORIMANAGER OTHER AUTHORIZED AGENT Q <br /> rfArarlr.ANris not ax] proof of iuthorkadon to shirt is rnuirvd Ti[!o <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 envlronmentallsite assessment information to the SAN JOA4UIN COUNTY PU!)LfC HEALT3I SFJ3V10E5 ENVIrt4NFAENTAL HEALTH DMSIOtJ le 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 /> v«w � c S�r��ur �iix - drf <br /> COMMENTS: <br /> PAYMENT t <br /> j � lr �/ �. RECEIVEED <br /> SEP 6 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOhv <br /> I <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> E-ASSicNEDTo <br /> D B EZSPLOYEE#: <br /> DATE: <br /> : EMPLOYFE�r: �A2 DATE:q_ d (f <br /> .'Date Service Completed (if already completed): - SeRVICECao>: r' <br /> =PlE: / ;: <br /> : J <br /> Fee Amount : `j <br /> Am❑unt Paid G Payment t?atc <br /> Payment Type C Invoice#' Check# vCJ <br /> Received By: <br />