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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE VICE REQUEST# <br /> OWNER OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITEADDE55 5 �wy 9/ IrRO/V%iTc� <br /> $but Numbr drecUon svM Numu TTp� Saibl <br /> Mailing Address (If Different from Site Address) <br /> CITY Ste© C,IC w STATELP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> c 2 - e 3L� <br /> PHONE#2 Fxr. BOS DISTRICT - LOCATgN 000E - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR l BILLING PARTY <br /> O6/ G/fIF.l-N% <br /> BUSINESS NAME PHONE# O ERT. <br /> MAILMG ADDRESS Pc o <br /> C/ .JL AX 9, CU <br /> CITY 2 L V G(e-- STATE CA <br /> LP 0� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor prejed specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OrvIs10N hourly charges associated with this projedoracUvity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared pplicadon and w rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws, p".�/,� �7y� <br /> APPLICANT SIGNATURE: fir A` DATE: [ C' G/ <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> ITAPP Tis not Un BntrvepA ,Proolofaerhorisadon to sign is mq 2 Ti tlo <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 environmentat'sile assessment information to the SAA JOAQUIN COUNTY PUDLIC HEALTH SERVICES ENYIRoNMENTAL HEALTH DmSION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Y r cic 14 IDti �T <br /> COMMENTS: I.-I--0 I <br /> 0-0 <br /> —/3-0\q c/� ' !'i°a� PAYMENT <br /> RECEIVED <br /> OCT - 3 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNATURE: ENVIRONMENTAL HEALTH OIVISIUN <br /> CONTRACTOR'S SIGNATURE: <br /> APPROVED OY:. —� <br /> EMPLOYEE 4! <br /> D DATE: <br /> ASSIGNED TO: �.rT U, _ EMPLOYEE �'/'6 <br /> t DATE: <br /> Dale Service Completed (if already completed): =-- <br /> `A �3 SERV CECooE: PI E:2Fpd� <br /> Fe0 Amount: Amount Paid �a r ? � <br /> �S ,c Payment Dat !�, 1 <br /> Payment Type T Invoice# <br /> Check# t <br /> / J Received By: _Zt� <br /> J <br />