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SERVICE REQUEST EH00615R revised 07/10/98 Type of Business or Property FACILITY ID# SERVICE REQUE I OWNER/OPERATOR /3AN,A S/ n/G BILLING PARTY FACILITY NAME SITE ADDRESS $fleet Number Direction Strut Name Type Suite# Mailing Address (if Different from Site Address) PO/ 167 / CITY STATE ZIP 9.Sel 3 Goc r� �� PHONE#1 Er. APN# LAND USE APPLICATION# PHONE#2 BOB DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTORFBILLING PARTY❑aN.�e.$)� F S f�i BUSINESS NAME PHONE# EU c.l P11 5- ANG,2 , 93/-13 7.5- MAILING 5MAILING ADDRESSFAX# S3 S5 e5-41crr Rancti (�^d, 931- Z373 CITY �fnc�c 7�cn C 4 • STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPUCANT IS not the BIWNG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is rovided to me or my representative. DL- TYPE OF SERVICE REQUESTED: Ifel/lcW Lor/ 7�CLly!l�a2�ze� i /l e o�7� COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER -------------------- ❑ °..dllN CUUNT'I PUsur�HEA.LTFI SEHVIOrS FNVIRONMENI:AL H6nl TH DIV6SION INSPECTOR'S SIGNATURE: CONTRACTOR'SSIGNATURE I ATE: I APPROVED BY: EMPLOYEE#: OuDATE: ASSIGNEDTO: �? n EMPLOYEE#: .� %� (�/ DATE: Date Service Completed (if already completed): SERVICE CODE S P 1 E: os Fee Amount: N/ �S L.cp Amount Paid /5( • p Q Payment Date Payment Type Invoice# Check# a 1-tL �F-3 Received By: