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SERVICE REQUEST <br /> EH0061SR revised 07/10198 <br /> Type of Business or Property C H URCH FACILITY ID# 'IUP-9� Y4 SERVI <br /> PRaFER"1'Y <br /> OWNER I OPERATOR <br /> (} ILLING PARTY <br /> FAC ury NAME <br /> SITEADDRESS 14,101 <2 a'ZAt4-tlt—IE 1Z0Ar);—rT,>ACyCA. 9� <br /> Street slumber DirecNae 5bed Name l <br /> Type Suite 0 <br /> Mailing Address (If Different from Site Address) <br /> CrrY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCAi10N CODE <br /> I CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR kcm? =r CU�T(S <br /> I�-►� BILLING PARTY <br /> BUSINESS NAME PHONE# ExT. <br /> C 1�c"I L �1�1C i N��R l �.�• � 115 - •... <br /> MAILING ADDRESS FAX# <br /> CrrY ( .OD STATE C fl zip 952 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL�04 ourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to b rformed will be done in accordance with all SAN JoAqulra COUNTY <br /> Ordinance Codes, Standards,STATE and FEDERAL laws. _ <br /> APPLICANT SIGNATURE: DATE: Q <br /> PROPERTY BUSINESS OWNER © OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> 1fAPPuc NT is not the BuurrG PARTY proof of authoriraSon 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, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> Pusuc.HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> St S <br /> COMMENTS SPECIAL CONDITION(S)OF APPROVAL❑ OTHER <br /> REC-EEVD <br /> FEB 19 1999 <br /> PI_IrLri;rl�s:_ih��r,�:�lcr=s <br /> lntv�VlF?rJia'h'tE{`dThLFtERti7': ;�,�ni - <br /> INSPECTOR'S 51GNA CONTRACTOR'S SIGNATURE: i DATE: <br /> I <br /> APPROVED BY: :.EMPLOYEE#' . DATE: <br /> ('. <br /> ASSIGNED TD: ()A !LI EMPLOYEEM DATE: L <br /> Date Service Completed (if already completed): SERVICE Co E: P I E: " <br /> Fee Amount: �� Amount Paid ��� � Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: <br />