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V <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BILLING PARTY ❑ <br />SERVICE REQUEST # <br />PHONE # <br />cit <br />E <br />t 3 <br />aEc <br />OWNER I OPERATOR <br />BILUNG PARTY <br />i1r--mo %I -, CA-r.t s<cPF� <br /># <br />l(0) <br />FACILITY NAME <br />GAArJ +`PA "S GAc t� W Pry N <br />STATE G44, <br />ZIP <br />SITE ADDRESS <br />A_ DDRES�S� \_ ,l-(..-,��_pT.,_ <br />i �� <br />��.1,—C-� .• <br />i ��� "� <br />DATE: <br />ASSIGNED TO: <br />�(Tr2^ Tom' SftdNumbw <br />Direction <br />Strut Name <br />SERv=CODE: <br />1y" <br />Suite# <br />Mailing Address (if Different from Site Address) <br />Payment Date 1-�_�- � <br />Payment Type ( I <br />Invoice # <br />Check # l l �"L ; <br />cITY; -oGKTocJ <br />STATE q 4-- <br />PHDNE#1 Ems• jAPN <br />")fid- - t (03 (o <br />; - obc) - 3S <br />\ <br />La(o USE APPLICATION #23� `t - $ <br />PHONE#2 Err. <br />BOS DISTRICT <br />LOCATION CODE, <br />CONTRACTOR! SERVICE REQUESTOR <br />REQUESTOR N1 t K-t� I �' _- <br />- 1' <br />CiISP t(`�SR=7�� <br />BILLING PARTY ❑ <br />BUSINESS NAMEm \ K �p �.-A �_T �_ <br />TS'_ <br />PHONE # <br />cit <br />E <br />t 3 <br />aEc <br />0 <br />MAILING ADDRESSFAX <br />3*00 Yvr ov > � _ <br /># <br />l(0) <br />CITY VL - SA -c,— <br />STATE G44, <br />ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ad site andfor project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Divlsm 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 prepared this application and that the work to be performed wit be dome in accordance with ad SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: L v"" Wv DATE: 7— 436 <br />PROPERTY/ BUSINESS OWNER TOR 1 MANAGGI ❑ OTHER AUTHORIZED AGENT ❑ <br />NAvatx wrisnottheI3rieecPurry proof ofwtho "fidntosign ismwkw rifle <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 andlor environmentallsite assessment information to the SAN JOAQUIN COUNTY Pusuc 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 />amu_ NSUJ —rp: �1t�—T p ,t (r\ ) lot (0, NGS <br />- 1' <br />CiISP t(`�SR=7�� <br />COMMENTS: <br />pp,Y EVES <br />aEc <br />0 <br />SP g�O NEP�SHEP�N�`V\S`ON <br />P �Nti�Et�Sn� <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EXPL'JYEE#: ` <br />DATE: <br />ASSIGNED TO: <br />EYPLOYtEE #: <br />DATE: / — 2— <br />Date Service Completed (if already mplettad): <br />SERv=CODE: <br />-P I E: <br />Fee Amount:`�� <br />Amount Paid 7$ <br />' <br />Payment Date 1-�_�- � <br />Payment Type ( I <br />Invoice # <br />Check # l l �"L ; <br />Received By: <br />7 yg <br />