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.... SERVICE REQUEST <br /> Type oPBusiness or Property FACILITY IDit <br /> $EKV 1C1Z REQUE$T � �� <br /> OWNER/OPERATOR 11``G <br /> BILLING PARTY 0 <br /> FAQILfTY NAME <br /> SfTEADDR SS dcd <br /> V Str..r Nu dI'on MM <br /> Mailing Address (If Different from Site Address) P. SQ.r <br /> CITY <br /> STATE Zip <br /> PHONE## EAr. APNB LANDUSEAPPLICATIONtt <br /> ( ) <br /> PHONE#2 Exr. BIDS DISTRICT LOCAT'AN CODE'. <br /> — CONTRACTOR I SERVICE REQUESTER <br /> LREQUESTOR <br /> OA) !-7 �D . 113UWGPARTYA <br /> NESS NAME PRONE#9 NG ADDRESS /v � FAxa <br /> G CL T-CJ Aj STATE <br /> C / S/ ZIP -Z <br /> /1 C <br /> BILLING ACKNOWLEDGEMENT: I, The undersigned property or business Omer,operator or auDlariled agent of same,acknowledge Brril all Site and/or Project specific <br /> PUBLIC HEALTH SERVICES ENVTONMENTAL HEALTH DIVISION hourly charges associated With this project or activity will be billed to me or my business as identified on ills form. <br /> I also certify that I have prepared Nis ap 'on.and That the work to be Performed will be <br /> done in accordance with all SAN JOAQUIN COUNTY Ordinance Cadcs,Standards,STATE and <br /> �FEDERAL WWI. �✓• "\ V`� �--L�C_/• p <br /> MPUCANT SIGNATURE: < DATE:_ l b Z� / / D J <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AURIol AGENT �' <br /> 1/Avrtuxris rM(Iho B2rc PurrY Proctorauthoriaation to sten Is npuk- Tifla <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the Omer or operator of the property located at the above site address,hereby audiorim the release of <br /> any and all results,goolechnical data and/or environmcmallsilo assessment intomztion to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNRIQV as soon <br /> as it is available and at the same 6mc it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: It <br /> �� � PAYMENT <br /> 7""ie �5 o� 9ACe )-f A-r_ O'e", s7� k RECEIVED <br /> 2001 <br /> SAN JOAQUIN COUNT`/ <br /> PUBLIC HEACIH SERVICES <br /> r ENVIPONAENTAL"FAL ;-''fl, <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGIlANRE: <br /> APPROVED BY:. <br /> k EMPLOYEE if: f+p��-) / DATE: I <br /> -ASSIGNEDTO: <br /> EMPLOYEE k: 6? DATE: <br /> :Dale Service Completed.if already completed): <br /> SERVICE CODE: <br /> fee Amount: ( � � <br /> `�l cI Amount Paid 5 Payment Date q/d <br /> Payment Type Invoice 9' f <br /> Check 0 Received By:�j <br />