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SERVICE REQUEST • <br />TypeA Business or Property <br />�) �c', b, � h <br />BUSINESS UM ECL � n� <br />� 1, :�r- 01 `j"�J' 10,12 <br />�T- <br />PHONE #4�1 <br />) <br />FACILITY ID <br />SERVICE �REQUEST #q <br />OWNER PERATOR <br />0 <br />BILLING PARTY <br />FACILITY NAME' <br />SITE ADDRESS <br />�eet Number <br />— Di on <br />/ 6' Street Name am <br />Type <br />Suite # <br />Mailing Address (If Different from Site Address) <br />CITY <br />INSPECTOR'S SIGNATURE: <br />STATEzip � <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />ASSIGNED TO: S , Sc, b r <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE OR J BILLING PARTY <br />BUSINESS UM ECL � n� <br />� 1, :�r- 01 `j"�J' 10,12 <br />�T- <br />PHONE #4�1 <br />) <br />MAILING ADDRESS�� <br />CITY STATE zip <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />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. <br />I also certify that I have prep 1ed this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. t` <br />APPLICANT SIGNATURE: r/ �.t� i ��� / DATE: I'(/ / / / 0"', s'J <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER El OTHER AUTHORIZED AGENT 1 _= `5 ' Lic ( � <br />IfAppucavris not the BIwwG Pvtry, 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, hereby authorize the release of <br />any and all results, geotechnical data and/or environmentadsite assessment information to the SAN JOAQUIN 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 />COMMENTS: <br />lry��[rigtiVd:-. <br />DEC 11 1998 <br />SAN JOAQUIN COUNTY <br />PU13UC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />iv"rn0'v'cv o`t: -rn , �� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: S , Sc, b r <br />EMPLOYEE #: )LI S ( <br />DATE: <br />Date Service Completed (if already completed)". <br />SERVICE CODE: <br />�0 <br />P I E: j <br />Fee Amount: 023 <br />Amount Paid f;,' �3 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check #a <br />Received By. <br />