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SERVICE REQUEST <br /> Type of Business or Property ----[FACILrrY ID# SERVICE REQUEST# <br /> E D n/ IAL Q 2 ,-91 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> /A19-5. MARY SG/K <br /> FACILITY NAME <br /> $ITE DRESS / Out Jaeas Street Number Direction v street Name Type suite' <br /> Mailing Address (If Different from Site Address) <br /> CRY ?I POAI STATE ZIP 175-1 <br /> PHONE#11 Ear. APN# LAND USE APPLICATION# <br /> c ) X03 -070 — ;27 ND tit5 <br /> PNONE 92 Ear. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR DON BILLING PARTY LA <br /> BUSINESS NAME 1 / �J <br /> V G4� 2C PHONE# <br /> MAILING ADDRESSFAX# <br /> R.O . l� K 79� —ZS <br /> CITY G STATE /rA <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 DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified an this form. <br /> I also certify that I have prepared application and a work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. •� <br /> APPLICANT SIGNATURE: DATE: Z t3 �Q <br /> PROPERTY I BUSINESS OWNER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> I/APat.GAVTsntvhaSlumc Pam.proororaurhorbadon tcsignisrepur Title <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 envimnmentallslle assessment information to the SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> RG GE Su6Sll�/Z`a :E Nf4TioN gPo T EW <br /> COMMENTS: <br /> RECEIVEn <br /> FEB 2 32000 <br /> SAN JOAQL'N COLI, y <br /> �'UtBUC HEALTH SERVIrrS <br /> INSPECTOR'S SIGNATURE: °NVIRONMENL7L HEALTH CV JIS .r <br /> CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: '? '7 tel <br /> "1 2!-D <br /> ASSIGNED TO: y L EMPLOYEE M. DATE: L L^ <br /> Date Service Completed (if already mpleted): 3 SERVICE CODE. L PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type t",_ Invoice# Check# Received By: <br />