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• SERVICE REQUEST <br />Type of smess or o erty <br />BILLING PARTY I <br />FACILITY ID # <br />SERVICE REQUEST # <br />All <br />PHON # _ J EXT. <br />�� 0 54a <br />S UI 3oz zo <br />OWNER I PERATORCA,,, <br />BILLING PARTY ❑ <br />FACILITY NAME <br />STATE zip q �j <br />SITEADDRESS <br />r1 <br />j X1{"/17 <br />�W <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />Street Number <br />Direction <br />Nine (J IJ <br />Type <br />Svitl I <br />Mailing Address (If Different from Site Address) <br />, <br />n <br />l� <br />r /-I <br />1 <br />CITYb�r <br />STATE ek ZIP <br />1. <br />P(HO�NE#'i <br />APN# <br />LAND USE APPLICATION# <br />Fee Amount: <br />Amount Paid �d (v <br />Payment Date (p/ q /0 Z <br />PHONE #2 <br />Rig <br />Check 0 & o 3y- <br />BOS:DISTRICT LOCATION CODE.. <br />A CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR ( I ! <br />BILLING PARTY I <br />BUSINESSNAM <br />t- <br />f 1 /g <br />�� <br />PHON # _ J EXT. <br />MAILING ADDRESS <br />t` <br />PAYMENT <br />FAX # i <br />CITY /1 <br />STATE zip q �j <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 projector activity will be billed to me or my business as identified on this fonn. <br />I also certify that I have prepared application and that the w rk to be performed will be done in accordance with all SAN JOAOUiN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL IawS. <br />APPLICANT SIGKMATURE kvi DATE: C401N <br />PROPERTY/BUSINESS OWNER O OPERATORIMANAGER ❑ OTHER AUTHORIZED AGENT <br />If Aaauowr is not rhe Burrs Purry proof of authorization to sign Is re-quirad —Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property Iocated at the above site address, hereby authorize the release of <br />any and all results, geotechnical data and/or environmentallsile assessment information to the SAN JoAwN 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 />V <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JUN 19 2002 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />FNVIRONMEN1tAL HEALTH DIVISION <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVEDBY:.EMPLOYEE#: <br />%� s �� <br />�yjj -2,DATE: <br />l� <br />ASSIGNED TO:�d, v <br />EMPLOYEE #: (i O J <br />6 D <br />DATE: ✓ r <br />1 <br />Date Service Completed (if already complete : <br />SERVICE CODE: I <br />.P l E: --2� 3 0� <br />Fee Amount: <br />Amount Paid �d (v <br />Payment Date (p/ q /0 Z <br />Payment Type ✓ Invoice #' <br />Check 0 & o 3y- <br />Received By: <br />I <br />FNI <br />