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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T# <br /> I <br /> OWNER I OPERATOR <br /> L`` BILLING PARTY <br /> FACILITY NAME <br /> i <br /> SITE ADDRESS —1 ooh <br /> Street Number Direction Street Name -7 Type I Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> gS33 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY El <br /> BUSINESS NAME 1 PHONE# EXT. <br /> 7- -3-7c I <br /> MAILING ADDRESS FAX# <br /> aK) wm <br /> �Clf: <br /> STATE C_ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated With this project Or activity will be billed to <br /> 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 will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, S TE and FEDERAL la <br /> APPLICANT SIGNATURE: � DATE: �,/t <br /> i ✓ V <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El- <br /> If <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> 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. <br /> TYPE OF SERVICE REQUESTED: L./' iL <br /> r, //�„ JJ, -/, <br /> COMMENTS L'J SPECIAL CONDITION(S)OF APPROVAL IQ OTHERZ71 & L�Iai L <br /> `C (�J� '�( ❑ <br /> iZI w4_ <br /> �i/ j <br /> SAI, IQAOUIN C <br /> / FNUIRON C.H�AL7H S oUNT y <br /> i. <br /> INSPE R'S SIGNATURE:, C TRACTOR'S GNATU E: L7H DlviSlr,DATE: <br /> APPROVED BY: EMPLOYEE#: DATE: 7 3 0 . <br /> ASSIGNED TO: kd Snj i. EMPLOYEE#: DATE: 3 <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E: D• <br /> Fee Amount Amount Paid j S- Payment Date 710- f P <br /> Payment Type G�� C Invoice# Check# 2 3 Received By: <br />