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i <br /> w <br /> SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or PropertyFACILITY ID# SERVICE RE ST#AMIJ SA6 <br /> r� i D°3 Elm a <br /> JY'r'NER I OPeRATO <br /> �•t � /"J BILLING PARTY❑ <br /> V ! i <br /> FACILITY NAME <br /> SITE ADDRESS <br /> StreetNumberJ Direction Suite# <br /> Mailing Address (If Different from Site Address) ! , <br /> CITYi�v �, E ZI <br /> C� :]:APN <br /> 2Z r ID� <br /> PHONE# EXT. # LAND USE APPLICATION# <br /> a 7�a- y <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR /l� BILLING PARTY <br /> BUSINESS NAME �J PHONE# T• <br /> MAILING ADDRESS0115- / F d9&)'7 Y& <br /> CITY )n TATE ZIP q/� <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 t0 <br /> me or my business as identifi on this form. <br /> I also certify that I have ep ed this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Stand rdS, TATE and FEDERAL law p` <br /> APPLICANT SIGNATURE-�-�"�� ✓ ��U/ DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT / <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: <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> PAYMENT <br /> MY 20 <br /> SANJOAQUIN CVUNTI• <br /> ENVIRONMENTAL HEALTH DfV&ON <br /> .......... -......- —......- - ------ ---- --- — - -- —— <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: 1 � A , ,� EMPLOYEE#: / -� t DATE: � <br /> ASSIGNED TO: S �S 6- EMPLOYEE#: DATE: S 2,11 <br /> Date Service Completed (if already completed): SERVICE CODE: / P 1 E: '2—'3 c <br /> Fee Amount: Amount Paid P yment Date <br /> Payment Type Invoice# Check It Received By: <br />