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�.. SERVICE REQUEST J <br /> Type of Business or Property LFACIL,"111# <br /> SERVICE <br /> �RE/QUEST# s—7 <br /> ig <br /> OWNERI OPERATOR — � J <br /> 1 e✓ BILLING PARTY❑ <br /> 1FACILRY NAME <br /> SITE DRESS <br /> Az L5 \ <br /> strrHHvmEr e�von H+mr (C( Qh <br /> Mailing Address (If Different from Site Address) / Tror sw.a <br /> Pn U 0 �ur <br /> Crrr <br /> C- I t STATE LP <br /> PNON01 Fsr. APN# - LAND USE APPLICATION#/ <br /> PHONE#2 <br /> BOS OLSTwcr Locaoi CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> A . BILLING PARTY❑ <br /> BUSINESS NAME <br /> PHONE# Esc <br /> MAILING ADDRESS <br /> FAx# <br /> CITY <br /> STATE LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property of business owner,operator or authorized agent of same, acknowledge that ail site and/or project specirk <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION howdy Charges associated with this pmjector activity will be billed to me Or my business as idenGried on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all Sur JOAQUIN COUNTY Ordinance Cedes,Sfandardt,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> uAva,cwri:nNflu Qrtismevrry:A•oororaufhairadon to afen Is roVufrod info <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1,the owner or operator of the property bcated at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envifonmentaVSite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvuiONMENTAL HEALTH DIVUIDN as soon <br /> as it is available and at the same time it c provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVED <br /> SEP 2 1 2000 <br /> -. SPlf8llO HpP HE ftR�StUN <br /> ENNRDNMEN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE � / <br /> � DATE: ;to -ZIPa <br /> -'ASSIGNEDTO: -Zi /A& EMPLOYEE#: � /J2 ZI <br /> 7 d -DATE: -I-& -zw <br /> :Date Service Completed (if alreadyy co completed): - � - <br /> SERVICE CODE: <br /> �.2��i - Pl E:.2� <br /> Fee Amount: �� ,QQ Amount Paid <br /> Payment Date <br /> Payment Type C Invoice#' Check# <br /> lj Received By: <br />