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� R 3v^.'r•H�-�`- /�� 1:f3`�,•r�'F'HC1✓. Cn t.:�t"",M;t-i A-T'�e�i�1 '� �f�G:T ' ti SERVICE REQUEST EH0061SR revised 09/04/98 Type of Business or Property FP,Gt'r'-EL''` '` ', - +F ` r` =' FACILITY ID#ti� "' tP�r'` SERVICE R Q EAST QfSli� t 1��AL 0 1' Fri (ji i l OWNER/OPERATOR C�l7S�'C• A1aD �anl.f+ 1iAMl� T11J+ •� BILLING PARTY (GEC.>1?4i� i-IAi�A i iN I rTFZl�tt�.�`T1Zu"�� FACILITY NAME HKS fie ►w Fti•�'� PRE�E,-��t.�Y Ktvp f r 4@ s SITE ADD SSE^S'C, iFtSRtrrz P'3 �l �E►i' 3 ►C�.'��t cS r s /� t =.� 19 SJ Number Direction Street Name Type Suite d Mailing Address (If Different from Site Address) Mk• A%AAhoc> N4J�4 E-". t.'Af'P°trY) 14-0? FP_ rrtioty,- CITY , STATE ZIP PHONE#1 EXT. APN# j71 LAND USE APPLICATION# 26y $z-5_4,5'C' i PHONE#2 F AX EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTOR YdAtiZ;Q 'E [►IJR,'T1 S BILLING PARTY❑ BUSINESS NAME PHONE# ExT.S Tt C 11r1rj. MAILING ADDRESS FAX# CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific 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. 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 Ordinance Codes, Standards,STATE and FEDERAL laws. APPLICANT SIGNATURE: G L % '/ -E DATE: /+-2'2--99 PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT JAS 1,t la MG 1 N1` P_ IfAPPUCANTis not the BwNGPARTY,proof of authorization to sign is required Title 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 any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY 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. ii c_c TYPE OF SERVICE REQUESTED: A1-aV 5�1•�r-� 1"` 1 �F�.4 i E•v'F COMMENTS ❑ SPECIAL CONDRION(S)OF APPROVAL❑ OTHER ____ —�❑ APR 2 2 1 -----........ --._..__...._...... _.�........._...._.... INSPECTOR'S SIGNATURE: CONTRACTOR'S SiGNATURE: DATE: APPROVED BY: l EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: �— I Date Service Completed (if already completed): r .� L SERVICE CODE: P I E: C) . Fee Amount: L c- F� Amount aid Payment Date + a a Payment Type Invoice# Check# Rrer ived ry: