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SERVICE REQUEST <br /> Type of Business or Property _ITY IC a SERVICE RQQUEST# <br /> ose Sf 4949L rJJ <br /> OWNER/ OPERATOR <br /> UN I tr EP-5/ uBL l �G D O L7 CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> I(��25� Ll�Ltc SCHooGS <br /> SITE AD RESS /V y�(r�k1A�/ <br /> /0077- Street Numb I tbn / 5 tNa e Type ui # <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> S76CK oN CA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR /� !•Jr <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE E' . <br /> QtlAL/ GON'Tre0L /NSPEGTI Q Al S�z7-A94v <br /> HOME Or MAILING ADDRESS FAX# r; 7 <br /> z9 S EMFizAZ-D ®.✓E ( 9 <br /> CITY9j 33 <br /> Q D E S i Z) STATE`� IP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified 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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA and FEDE laws. <br /> APPLIC.+.NT'S SIGNATURE: DATE: <br /> PROPERTY! BUSINEss OWNER OPERATOR/IIMANAGER ERAUTHORIZED_A <br /> IrAPPL/CAM is not the BILLING PARTY.proof of aur onZan !O Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirortmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. ,' s <br /> TYPE OF SERVICE REQUESTED: PE2G TEST /�'b 2T C` (/I� ✓`� <br /> COMMENTS: <br /> l <br /> INsPECrOR's SIGNATURE: CONTRACTOR'S SIGNATURE: - <br /> APPROVED BY: 11 <br /> EMPLOYEE#: / DATE. 3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> I <br /> Fee Amount: Amount Paid Payment Date ; ` <br /> Payment Type ! Receiipt# I Check# Received By: <br /> SRREOrev.doc I, I4 y 1.YJ (W vy') - 7/1/1999 <br />