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-j-01 `a�p ��� <br /> _ SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY <br /> FACILITY NAME �\ �'�I �$eC V� <br /> I`f's <br /> SITE ADDRESS a►S "3 LL)�7j �� ��(t5lnwec� �{q f9 caVrflo CIS} <br /> Street NumbeY Direction SVeet Name Type Suite: <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LA ICATION# <br /> rM 6k 5 99l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUIESTOR <br /> REQUESTOR !/\ IV) <br /> N BILLING PART-113 <br /> lit �l � <br /> BUSINESS NAME PHONE# —+�� / EXT* <br /> do 67 <br /> MAILING ADDRESS FAX# 5 <br /> Lo. 33 - X303 <br /> ' CITY � _ n t �1Q � ( I� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project Or activity will be billed to <br /> 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 COUNTY <br /> Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address. <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER_ ❑ <br /> �j PUBLIC HEALTH ERVICES <br /> rIOR'S <br /> //�Q' —AM � �J4,YI&--- � 7ENVIRONMENTAL HEALTH DIVISION <br /> SIGNATUR�� CONTRACTOR'S SIGNATURE: //�V DATE: <br /> t <br /> APPROVED BY: EMPLOYEE#: q(� DATE: ( [g QJ 9 <br /> l ASSIGNED TO: 1, `G CL � EMPLOYEE#: 5 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S`-? 5- 1 PIE: (32-60 <br /> Fee Amount: 90 / 5 Amount Paid oe <br /> i <br /> 5 D7�� Payment Date <br /> Payment Type Invoice# Check# a Lf y S Received By <br />