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I" 8-25--19Y8 3: b8PM F RUM N. <br />SERVICE REQUEST�� r <br />kyof Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER I OPERATOR BILLING PARTY <br />GF4 E�(CL-e� hiobu G'j S Conte`! <br />FACItm NAmj <br />SITE ADDRESS(�M' <br />Isa..c M�.ee. Ornctly� <br />Mailing Address (if Different from S'te Address) <br />Cm 6A,1 <br />PHONE III <br />(1*) 9A'Z • �OUz <br />PHONE #2 °R <br />- - STATE Gf3 <br />APN 9 LAND USE APPLICATION It <br />UOS DISTRICT <br />CONTRACTOR I SERVICE REQUESTOR <br />Zip a,+S G <br />LocATIDN.Coua <br />Saw S <br />--- <br />RFOUESTOR <br />BRIAG PARTY ❑ <br />BUSINESS NAME <br />U <br />PHONE# qa- <br />•To'}) 3 <br />-G'-- <br />MAILING ADDRESS <br />[Ib-1Oc-pov)UL �WD <br />FAX # <br />01 1 b5 -- gg0�8,(� <br />-- <br />CITY A l �� m A <br />l.{/1 T <br />G <br />STATE 6A zip q l I I <br />BILLING ACKNQWLEDr?L:MFNT_ L the undem9fled property or husinms owner, oparatnr or authored agent of Seam acknowirsdge drat alt site and/or project spec+c <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DwlstoN hoarty charpR3&nsocated with the projed or BCfv$y wW be bOM to me or my business as ident6Od on this fomt. <br />1 also rartify that 1 have prepared the applicadw and drat the work to be performed will be done in a=rdamm with al SAN .IOAOUIN COUNTY Orati maw Coder, Standards, STATE and <br />FFDFAAL laws. A /q 8 <br />APPLICANT SIG+� <br />DATc_�l NATURE: 11 <br />PROPERTY I R ISIW3MS OWN ❑ OPERATOR I MANAGER. ❑ Cnfe T Atfn+ORGED AGENT X , C i A l <br />KAPPir-wTisto teSum2 rosi"isroo r'd rill* <br />AUTHORIIATtQN TO RELEASE INFORM When apprimbte. 1• the owner or operator of the property locaeed at the above site address, hereby audtorlzA die roka%e of <br />any and at results. genW_hnicai data and/or environmentallsite assessrnent infornalim to to SAN .loAW m COUNTY PuaLic HEALTH SETmcxs ENV"UENTAL HEALTH DA S as Soon <br />as it is avaitable and at the same time It is provided ie ma or my represerdaM. <br />TYPE OF SERVICE REGUESTED: <br />Cor+Itict'xrs: <br />I Ai;T-AL L O BUJ Va-DEr • 00 PAYMENT <br />RECEIVED <br />Nov 5 1998 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACMies SIGNATURE: <br />(- <br />Em M`.` k (}��T 1 <br />OATS' <br />APPROVED BY: ( <br />PA � <br />i <br />_ <br />Assxiii -ro: j n /1 f �/ (/ <br />\-C <br />EIIPZOYi��f:�' <br />c� (� <br />DATE J� <br />Date Service Completed (if already coomptated)_ <br />SEmntE CODE: I � � <br />PIE- <br />IEFee <br />FeeAmount:(7 Amount Paid <br />Payment Date <br />-— <br />---- <br />Payment Type <br />lavoice # <br />Check # <br />Received Sy <br />