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SERVICE REQUEST EH0061SR revised 07/10/98 Type of Business or Property FACILITY ID# SERVICE REQUE T# OWNER/OPERATOR \ �—t BILLING PARTY FACILITY NAME SITE ADDRESS 1 Cod Street Number Direction Street Name Type Suite# Mailing Address (If Different from Site Address) CITY ,�^ STATE ZIP PHONE#1-1\ \K/ Y \ EXT. APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTOR BILLING PARTY❑ BUSINESS NAME PHONE# ExT. -3(,o7- -3-701 MAILING ADDRESS FAX# a m a CITY STATE / � ZIP qj SQ 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 to 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, S TE andFQEDDEERAL la APPLICANT SIGNATURE: ��/• DATE:— PROPERTY/ ATE:-PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT Is not the BILLING PARTY.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. TYPE OF SERVICE REQUESTED: --:Q,^LI n - �� COMMENTS �l SPECIAL CONDITIONN((,S)OF(APPROVAL 12 OTHER 'L ❑ i If 1 .a / / 1-/VV N JkLlc`Ik ti�.NJlIv C+::11v'j r U(, INSPE R'S SIGNATURE: j C TRACTOR'S GNATU E: ! H G1VISfgkDATE: I APPROVED BY: EMPLOYEE#: DATE: 7. 3 a Q ASSIGNED T0: �� Sn EMPLOYEE#: DATE. 3 Date Service Completed (if afready✓completed): SERVICE CODE: / P/E: `� O Fee Amount .1 Amount Paid /s6 Payment Date 7'10- FP Payment Type C-/,p C �� Invoice# Check# i z 3 Received By: