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SERVICE REQUEST <br /> Type rop <br /> t Business or Perty FACILITY ID# <br /> SERVICE REQUEST#� <br /> OWNER I OPERATOR BILLING PARTY <br /> FACILITY NAME <br /> SREADDRESS (_� I /Jn �f�a�//GC' C �'/ �/f/ <br /> HYmEr 04ectian //C/ •� � � Tryu Wt.r <br /> Mailing Address (If Different from Site AddressL n <br /> Cm ' f'1 STATE ]gyp <br /> PHONE#1 Esc. APN# LANDU$ APPLICATION# <br /> PHONE#2 Ear. BOS:DISTRICT - - LOCATgN CODE <br /> CONTRACTOR I SERVICE REQUESTOR - <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME <br /> PHONE J# <br /> MAILING ADDRESS FAX# <br /> CfiYf1(l STATE Zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or usinesI as Ido on this form. <br /> I also certify that I have prepared this a IicaUon and Thal the we o be performed will be done in a=rla AN O IN 0 anco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGHAT _ <br /> PROPERTY I BUSINESS OWNER D OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IIAPPtA'inrisnotthetfuwoPAmY poolelauthorT:agon to sign is requhvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the pmpeny lOcaled at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmenlallsite assessment information to the SAN JQAWIN COUNTY PUBIIC HEALTH SEHm es ENviRoNMENTAL HEALTH Div SION as 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 /> A <br /> To <br /> COMMENTS: <br /> 7 7�/ <br /> l REC ' <br /> - -tic3*0 "# (oo h 1 '��700Iu <br /> p <br /> AP!Ji <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: DATE: <br /> G// -J^/ 4/ <br /> ASSIGNED TO: 6 ll EMPLOYEE#: Dl DATE: _/ D <br /> Date Service Completed (if already completed): - SERVICE CODE: I S� .P IF /p cp'y <br /> Fee Amount: c �S Amount Paid �!� <br /> Payment Date I <br /> Payment Type Invoice#, Check# - Received By: --- - <br />