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SERVICE REQUEST Ak <br /> Type of Business or Property NOW FACILITY 10# SERVICE REQUEST# <br /> KE 0 N CL ,1� <br /> OWNER OPERATOR ILLING PARTY LJ <br /> Sl n\ t PAT DWILAVY <br /> FACILITY NAME f' r /t n (J 11 •t"1©o Q (K C VI—.F's <br /> SITE ADDRESS � +} 1� /T J/� 1—I FF f RV <br /> �3a27 G . - CIF t <br /> nt Mumbw Olnnlon Stns Nsme irDs Sw1f 1 <br /> Mailing Address (If Different from Site Address) <br /> 3r 17 - D <br /> CRY�> CA L .0 k) �/�ATE ZIPS 5 <br /> PHONE#1 APN# LAND USE APPLICADON# <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQIIESTOR BILLING PARTY❑ <br /> v <br /> BUSINESS NAME PIIONf# PT. <br /> h1AlUNG ADDRESS FAx <br /> CTTy STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busines; owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OrvisioN hourly charges assodated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certity that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANTeS�SIGNATURE: DATE: l�° ✓`0 <br /> — q q <br /> PROPERTY!BUSINESS OwN OPERAT 41 MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPuc,wr is no(ft Bum PAR rY proof of authorrsa don to sign Is r*Vkod Title <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 and/or envlronmentaV9ile assessment into mation to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEs ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same brae it is provided to me or/my representative. <br /> TYPE OF SERVICE REQUESTED: l JC^� /' Il <br /> COMMENTS: r l�V� � <br /> �VED <br /> J030iffin <br /> SAN.Jra,%QUIN COUNTY <br /> Pt."11-10 HEALTH St=RVICES <br /> ENVIRONMENTAL HEALTH DIVISON <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: 0 ( DATE: <br /> ASSIGNED T0: EMPLOYEE#: t� DATE: b^Z ` ! <br /> Date Service Completed (If already completed): SERVICE CODE: 522 P <br /> Fee Amount: 5 ( , o � Amount Paid Payment 4ate � <br /> Payment Type `� Invoice# Check# ���� Received By: <br />