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0 SERVICE REQUEST EH0061SR revised 07/10/98 <br /> ZTyZC>L'1 �4e: <br /> f Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER OPERATORBILLING PARTY <br /> FACILITY NAME G H E,Y D <br /> SITE ADDRESS 33C,5; � tion 11x/11./1 L 2me ^^v <br /> Street Number Direction n�\I"��`� � Street Name Type Suite <br /> Mailing Address (if Different from Site Address) <br /> I?t�, 15cx <br /> CITY A STATECA zip 9--.5 8 3. <br /> PHONE#1 EXT. 7yv') <br /> PN# LAND USE APPLICATION# <br /> 925 2 DDZ C-K, ,Zohifr <br /> PHONE#2 Q °cT BOS Dwpi.cT LOCATION CODE <br /> Z C� <br /> /4 v G c>w Gam, CONTRACTOR/SERVICE REQUESTOR <br /> RE LE3 T CR <br /> $1 KK K[+L BILLING PARTY <br /> BUSINESS NAMEL- � t'� P(7-7#lsi+ <br /> MAILING ADDRESS C IVD <br /> AX c <br /> ots <br /> CITYh (, A LS� STATE- <br /> 6A , <br /> z'P <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 1 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 <br /> �STL laws. N l N5U5p <br /> APPLICANT SIGNATURE: <br /> DATE: ��j,�1N 15 9 2' 5u15 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ia <br /> ER AUTHO�toslgl <br /> �il <br /> jK�kR L, PRRi��T AKsy t l 'T' <br /> IfAPPLicANT IS not the BILLING ARTY.pro0uthorization required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, 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 /> Pueuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided t0 me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1LAW w. UST :5Y. � <br /> 5T <br /> Co .. t1TS ISI c?ECS:CONOfPCNlS)OF APPROVAL rI OTHEP d Q <br /> � <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> i <br /> APPROVED 8Y: EMPLOYEE#:. DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid I Payment Date <br /> Payment Type Invoice Check# y. <br /> Received B <br />