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SERVICE REQUEST <br /> Type of Business or Property - FACILITY IDR SERVICE REQUEST/t <br /> l 7 4—/ I <br /> OWNER/OPERATOR BILLING PARTY <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �� -�/�✓F.��tFet NumEr Direction S V t N=$ - <br /> 'YDe I Surtei <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE'#1 APN# LAND USE APPLICATION n <br /> , -12-'V <br /> PHONE n2 `-ST• BOS DISTRICT LOCATION CODE ` <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR � BILLING PARTY x <br /> BUSINESS NAME PHONE# EXT. <br /> MAILING ADDRESS FAX'# <br /> �Du �l I I <br /> CRY � �' STATE 75�� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and.lor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION hourly d�,arges assccated with uhis 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 well be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: J!���/��T/ 1�� DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER O OTHER AUTHORIZED AGENT 11-K F/Y� <br /> N APa,,c.wr is rqt ft 8LL i,c PutrV.prod of authorization to sign is requirvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,].the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnlcaf data and/or environmental/Site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> COMMENTS: /J <br /> PAYMENT <br /> Pr <br /> MAR - 1 1999 <br /> SAN JOAQUIN COUN-,Y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIO^I <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: f/� <br /> APPROVED BY: // � EMPLOYEE : DATE: <br /> EMPLOYEE 4: DATE: '7 <br /> ASSIGNED T0: � /' .7 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: �i �� Amount Paid q 3'�D — I Payment Date <br /> Payment Type ✓ Invoice 9 Check R 3 a Gf;... Received By: <br />