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SERVICE REQUEST <br /> Type ofj3usiness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> L')QXf /!�G�� BILLING PAR <br /> FAcI NAME <br /> (�, u TY <br /> YV�S <br /> SITE ADDRESS140-75 1 1V'way <br /> /� <br /> Strett Number Direction 1 I �' ` a ama <br /> TYVe SuNe R <br /> Mailing Address (If Different from Site Address) <br /> CITY Lo <br /> r> ' STATE ZIP <br /> O <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2CO - ► 2 afv3- I u 0- (u <br /> PHONE#2 ° EXT. BOS:DISTRICT LOCATION CODE' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> TlF,V; NI FINK, <br /> BUIN <br /> MIL <br /> PHONE# Ext. <br /> M1 L O Irl DEkSOAl OG zpqt3 / <br /> MAILINGDRESS FAX# <br /> zZ N. vs7vu ZO9 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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 will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. ��++---- j <br /> APPLICANT SIGNATURE: DATE <br /> : J�a /D <br /> PROPERTY/BUSINESS OWNER 0LJ — OPERATORIMANAGER ❑ OTHER AUTHORIZED AGENT <br /> J��/i/_`�t� � <br /> If Aavrcwr is not the Bauvc Pam v proof of authorization to sign is req rvd 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 environmentallsile assessment information to the SAN JOAQUIN 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 /> 5 e y•.' <br /> COMMENTS: RECEIVED <br /> MAY262W <br /> SAN JOAQUIN COUNT Y <br /> PUBLIC HEALTH <br /> SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE' CONTRACTORS SIGNATURE: <br /> APPROVEDBY:. EMPLOYEE#: /^ -I DATE: Z <br /> ASSIGNED TO: EMPLOYEE#: L� DATE: S �� /��03 <br /> Date Service Completed (if a ady completed): 62 ( ", SERVICE CODE: .PIE: <br /> 42 <br /> Fee Amount: r Amount Paid ��" <br /> ( q b -7 Payment Date Sja3 �D <br /> Payment Type Invoice# Check# 021 3 I Received By: <br />