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6- SERVICE REQUEST EHOO61SR revised 07/10/98 Type of Business or Prope � } 1 I PHO # EXT., FACILITY ID # SERVICE jREQU T_y# o f I ) OWNER I OPERATOR � s r� V 4 BILLING PARTY ❑ FACILITY NAME S -e Cron DEC 11 1998 SREARDRESS Street Number �r^� " Direction 1' VWv �c "-q �`leA. "' Type Suite# Mailing Address (If Different from Site Address) CITY ( C I vT� cJ INSPECTOR'S SIGNATURE: S TE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. I BOS DISTRICT LOCATION CODE CONTRACTOR ! SERVICE REQUESTOR REQUESTOR V . / W e ,%A BILLING PARTY " BUSINESS NAME l ucfvc� PHO # EXT., MAILING ADDRE$S-�� FAX # n 1 `p l CITY ° (—,--?TATE 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 to me or my business as identified on this form. I also certify that I have prepar d this application �nd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes; Standard , T T FE ERAL la APPLICANT SIGNATURE: DATE: PROPERTY PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 1 If APPLICANT is not the BILLING PARTY proof of authorization to Sign is required Title 63N\S, 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: / '"r I J COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER DEC 11 1998 I r 4LL1 JOAQUIN COUNT ENV IC HEALTH l SEav- LTH DIVIS10" INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: APPROVED BY. EMPLOYEE #: I DATE: / l' ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CGDE: 07cf I P/ E: (9 Fee Amount: CI_ Amount Paid r Payment D to 1-49 Payment TypeInvoice # Check # Received By: