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• � � SERVICE REQUEST <br /> Type of Business or Property. FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY <br /> �Ew <br /> FAC NAME <br /> V v-vin S <br /> $READDDRESS <br /> 23 `5 Street Number Direction <br /> Street Nine TYVe sufle/ <br /> Mailing Address (If Different from Site Address) <br /> � I N <br /> Crnr LOsTACA 524C7 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (ZM 31p g - y-Co Z 003- Oy-D- O 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSIN SS NAME <br /> O� PHONE# /^� Fxr. <br /> E <br /> 1(— a <br /> MAILING ADDRESS FAX# W 1 <br /> CITY '✓O� STATECA ZIP <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 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. <br /> APPLICANT SIGNAT E' DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If Aver cmris not die Qu PARTY.proof of aurhodudon to sign Is requ J 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 environmentaVSile 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 /> COMMENTS: &/7/b U 4 T O � <br /> e s MY23 <br /> an <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAt.HEALTH DIVISION <br /> / > <br /> INSPECTOR'S SIGNATURE: /CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#.- DATE: <br /> V C/ <br /> ASSIGNEDTO: EMPLOYEE#: DATE:bY /V O <br /> Date Service Completed if already completed): <br /> SERVICE CODE: 3(� P I E: f . <br /> Fee Amount: P�b _ O U Amount Paid �-(0 _ Payment Date <br /> Payment Type Invoice#' Check# off) 3 18' Received By: C� <br />