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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of f siness or Pro erty FACILITY ID# SERVICE R UEST# <br /> ` ( <br /> OWNER I OPERATO <br /> j �, BILLING PARTY El <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ry Street Number / Direction Street Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY / ST TE ZIP <br /> PHONE#1 Yl EXT. APN# LAND USE APPLICATION# <br /> 02 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EXT. <br /> i <br /> MAILING ADDRESS FAX# <br /> 74/8 -16 4 0 <br /> CITY STATE ZIP <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 WIII be billed t0 <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standa s, TATE and FEDE L laws. <br /> APPLICANT SIGNATURE: f ` DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 71 _ <br /> ff 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 provid.pd p.q[,pr my representative. <br /> TYPE OF SERVICE REQUESTED: / <br /> r.( 2 <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> v JUACIOvy k,i)UNiY <br /> ILiC - <br /> ONMENTAL i-EALTH 1IV1510N <br /> JR <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: I DATE: <br /> APPROVED BY: 'P � �s,`. EMPLOYEE#: DATE: <br /> ASSIGNED TO: ` �`ZG EMPLOYEE#: 6 DATE: <br /> Date Service mpleW (if already completed): SERVICE CODE: -31 1 PIE: <br /> Fee Amount: 6, Amount Paid ° !3o --�, o e, Payment Date <br /> Payment Type Invoir Check# '4 qReceived By: <br />