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�.. SERVICE REQUEST ../ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST ttf/�Y <br /> OWNER OPERATOR <br /> BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADORESS Its <br /> Mailing Address (If Different from Site Address) `v.V sw.� <br /> CITY 0%,, STATE(/ . <br /> ZIP <br /> PHONE#1 Txt. APN# LAND USE AL^P LICATIOII# <br /> ( ) _ �1 <br /> PHONEHZ FiT. rl� `—� — �7 <br /> BOS.DISTRICT I LOCATION CODE' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REWESTOR C <br /> RIMG PARTY❑ <br /> 5 I BUSINESS NAME <br /> P1jQy� <br /> MAILING ADDRESS { ry O D ,��+ �� /� F x A <br /> Cm /� ` I XV I(\VI �0 <br /> F (� STATE LP Q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, Operator or authorized agent of same, acknowied a that all site and/or roject s <br /> PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly charges associated with this pmjW or activity will be billed to me or my business as identified on this form. ped(C <br /> I also Witty that I have39177 <br /> ' lion and that the rk Io be performed will be done in accordance with all SAN JoAOUIN CoONTY Ordinance Codes,Standards,STATE and <br /> FEDERAL Laws, /L�,, n APPLICANT SIGNATURE: /yl/I <br /> DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IrAxTxlwris fpr Ilia0_LUap r,Prooror aulhodaadon to sign is rxquimd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the ovmoror operalorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmenutsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DN61ON as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVIC[REOUESTED: Si <br /> COMMENTS: 1 <br /> MAY 1 0 2001 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. /l. EMPLOY <br /> E°#: O/,yam <br /> DATE: <br /> ASSIGNED TO: ((''�� <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: 5 2 4-- PIE: <br /> Fee Amount: 3 5 ab LTP <br /> Amount Paid 3 !J Payment Date �1 <br /> PaymentT e )— U <br /> YP Invoice# Check 0 Received By: V <br />