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0 SERVICE REQUEST it <br />Type of Business or Property <br />(2111.161c' <br />FACILITY ID # C <br />SERVICE REQUESTS <br />3a --7U7 <br />S''v f ,0O,f 7- <br />/Y S <br />BUSINESS NAME <br />�J���']' s%i¢N c%(�NajlJl <br />OWNER/ OPERATOR <br />EXT. <br />BILLING PARTY ❑ <br />PAYME <br />FACILITY NAME <br />MAILING ADDRESS <br />FAX # <br />SITE ADDRESS <br />vo <br />7 711 �C <br />Nam <br />,LIN <br />CITY �> a Cy 6 <br />U StrNNubv <br />ZIP <br />s <br />�I-Ne/f CAmp04 <br />TYW <br />Suite <br />Mailing Address (If Different from Site Address) <br />ENVIRONMEN P��H <br />INSPECTOR'S SIGNATURE: <br />•O, O O <br />APPROVED BY: 1 <br />l <br />CITY <br />EyPLOYt—=# b <br />STATE Zip <br />-�, <br />C A 4 / /-- 9G �a�iv <br />PHONE #1 UT. <br />APN # <br />LAND USE APPLICATION # <br />SERVICE CODE: <br />-PIE:—r)(� <br />PHONE #2 aT• <br />Amount Paid a 7 �$ C � <br />BOS DISTRICT <br />payment Type µELS invoice # <br />LOCATION CODE' <br />, <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />(2111.161c' <br />j- V ;:-- BILLNG PARTY ❑ <br />F <br />S''v f ,0O,f 7- <br />/Y S <br />BUSINESS NAME <br />�J���']' s%i¢N c%(�NajlJl <br />PHONE# <br />EXT. <br />PAYME <br />MAILING ADDRESS <br />FAX # <br />� 9 2000 <br />,LIN <br />CITY �> a Cy 6 <br />STATE <br />ZIP <br />BILLING ACKNOWLEDGEMENT. I, the undersigned property or business owner, operator or authorized agent of same, adcnowlEdge that all site ardor project specific <br />PUBLIC HEALTH SERVICES ENvtRONwxTAL HEALTH Dmxm hourly charges associated with Cris miect or activity will be billed to me or my business as identified on this toren <br />I also certif <br />'EDERAL la <br />APPLICANT <br />PROPERTY/ BUSINESS OWNER <br />wie be done in accordance with all SAN JOAouN COUNTY Ordinance Codes, Standards, STATE and <br />DATE O <br />OPERATOR / MANAGER ❑ OTHER AU 14ORRED AGENT Com- e <br />#APR r wris nor the ftumGPurry proof of "-ttntuBon to sign is Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicabl% 1. the owner or operator of the property located at the above site address, hereby authorize the release of <br />any and all results, geotechnical data ardor emrironmentalisite assessment information to the SAN JOAQUN 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 />/Y S <br />COMMENTS: <br />ED <br />PAYME <br />RECE1v <br />� 9 2000 <br />,LIN <br />cmrA <br />SPU L� HZ PRH 0� \S\ON <br />ENVIRONMEN P��H <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: 1 <br />l <br />EyPLOYt—=# b <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE # <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />-PIE:—r)(� <br />Fee Amount: _ <br />Amount Paid a 7 �$ C � <br />Payment Date orZp/p v <br />payment Type µELS invoice # <br />Check # 01 s' j>3 <br />Received 8y: - <br />