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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REEQUEST# <br /> L 2fkG S l T/�► C� ,� <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> 17AV r <br /> �ACIUTY NAME <br /> SITE ADDRESS I—A'r/-/n.�r <br /> 1-3 2,v Street Number Direction Street Name Type Suite p <br /> Mailing Address (If Different from Site Address) <br /> CITYSTATE ZIP <br /> TEC a /-/q <br /> �S 3 , <br /> PHONE#1 Ev• APN# LAND USE APPLICATION# <br /> 49 NVT <br /> PHONE#2 FBOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> r-0 , F-7-74 <br /> CITYSTATE ZIP <br /> F! 4%C.l « �S 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Or activity Will be billed t0 me or my business as Identified on this form. <br /> I also certify that I have prepared s application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> �/ <br /> APPLICANT SIGNATURE: / ��'� i � DATE: /Z I—A <br /> PROPERTY <br /> Z - <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR I MANAGER ❑ THER AUTHORIZED AGENT ❑ <br /> If APPLCANT is not the SiLuNG PA ary proof of authorization to sign is require! Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby aut orize the release of <br /> any and all results,geotechnical data and/or environmentaUsite 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 /> Sa/ 5./rA L rr TUo 4 ND N/ 77ZATF_ /nPAc r / ✓EJTi 4 A on/ 2EP-o,e7- REvi-Ew <br /> COMMENTS: <br /> - E1V U': <br /> 1 z- � ��t � ! h�. t2�>•ew <br /> NOV 22199.9 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> NVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: ��rL +� EMPLOYEE#: d 6 DATE: <br /> ASSIGNED TO: /IQ_ EMPLOYEE#: 2 g DATE: <br /> Date Service Completed (if already completed): � ��(� . (�C; SERVICE CODE: F1 E: � p <br /> Fee Amount: (�� Amount Paid fC6 Payment Date //17-Z—/,: <br /> Payment Type G,tfEG(i Invoice# Check Received By: �r <br />