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SERVICE REQUEST tea/ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BILLING PARTY <br /> u <br /> FACILITY NAME ,p <br /> SITE ADDRESS 0 t� . C m40. V�()�1L1 Ao'e- <br /> StreatNumber ebecuan V SM Name Type Tsestet <br /> Mailing Address (If Different from Site Address) <br /> CITY scaIC7" STATE �y 14 zip cl _3,20 <br /> PHONE#� APN# LAND USE JAPPLICATION# `` <br /> (a ) �) i-71 <br /> PHONE ff2 Fsa BOS DISTRICT LOCATN)N CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> N6 k c.�l� <br /> BUSINESS NAME 'I- PHONE# Err. <br /> S\ 14OUS L (dol 3rz)7- 70 / <br /> MAILING ADDRESS FAX# <br /> CITY Loci <br /> i STArE eq zip G!`r1r/v <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Oms:oN hourty charges associated with this project or activity will be billed to me or my business as identified on this fern. <br /> I also certify that I have p a This appliratio at the wo ed will be done in accordance With all SAN JOAWM COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL lam. <br /> APPLICANT SIGNATURE: ,,,,,,((( DATE: U <br /> PROPERTY/BUSINESS OWNER yy OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT ❑ <br /> / \ HAPPLuvTisnarfhe BUWGParrY.pml ofauthorrsadon to sign is required Tifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaVsife assessment Information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERmcFs ENVIRONMENTAL HEALTH DIVISION 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: - ^ p�! <br /> COMMENTS/ O (om <br /> n <br /> - oM/CCJ/t� efrr��ti� Sa unC� ��CE��J <br /> 0 <br /> a-L �e e.►4.1-e ui� � fi�<.S�.5�� `� 9 2p0 r <br /> y`ZFI/!� LCt�s/�- 'LP/J�7✓rq PU`O HEP NE�HDF�S\ON <br /> INSPECTORS SIGNATURE: COURRACTO^R'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: �}Cl DATE: <br /> ASSIGNED TO: EMPLOYEE#: 9 Gt49 I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S PIE: <br /> Fee Amount: 1 (� Amount Paid �l�., 7 L) Payment Date <br /> Payment Type., ,T;,i p- Invoice#' Check# %V��,� Received By: <br />