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<br />DATE: <br />OPERATOR / MANAGER D OTHER AUTHORIZED AGENT LI Ageli/ <br /> <br />If APPucANT is not the BILLING PARTY proof of authorization to sign is required <br /> Title <br />APPLICANT SIGNATURE: <br />PROPERTY / BUSINESS OWNER <br />SERVICE REQUEST <br /> <br />EH0061SR revised 09/04/98 <br />Type of Busiqess or P/operty <br />410 71V' <br />FACILITY ID # <br />_ <br />SERVIR <br />i <br />plifST.# —7s-- <br />. / <br />, / 7 ,,Yevi '44,0- I-i/A , <br />OWNER! OPERATOR BILUNG <br />i,/' 7;10774)'. <br />PARTY s <br />FACILITY NAME <br />SITE ADDRESS /7 , <br />;zv au /Stitrte3etZge Direction treet--Name <br />qr.376 /%1c9/6- Type Suite It <br />Mailing Address (If Different from Site Address) <br />10;4 3‘,/ 3/ry' tyl 6/ --‘/,9e iRrs 40a? A 14 <br />$ <br />0 <br />c, <br />7,7,y <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR BILLING PAR V .7-74yi a PARTY <br />BUSINESS NAME <br />t/ ii (:o. <br />PHONE # <br />r,-.) ....r.,--4--,/5---- <br />En". <br />MAILING ADDRESS <br />2 4 VO - I , . / //?C , i , - i %-/?e, / <br />FAX # <br />() 3* -:- 2 <br />CrrY /1//g1h- S-Tif) <br />STATL Zie. <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DiviSION hourly charges associated with this project or activity will be billed to <br />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 <br />Ordinance Codes, Standards, STAT an FEDERAL laws. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />Puauc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: :-) 1 c•-\ 1 <br />(0 0 k H ao CiCue? <br />OTHER COMMENTS II SPECIAL CONDITION(S) OF APPROVAL lill Il <br />.c,ryM ENI <br />Fo7:cF;v7r <br />OCI5 1998 <br />SAN JOALe0iN C.:C.)UN tY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE:n l : LATE: <br />APPROVED 13y4A, ( kAL-Qi EMPLOYEE #: 0 ( DATE: (b( C I <br />ASSIGNED TO: Aku. KSZN .3 EMPLOYEE #: qi 5 l DATE: fo ( ç. /t7 <br />Date Service Completed (if already ompleted): SERVICE CODE: 5 ,2...--; P 1 E: 3 <br />Fee Amount: 3 ( 4.,2„ 00 li Amount Paid 3i dI.ItJ <br /> Payment Date 10 .All <br />Payment Type N Invoice# Check # , <br />0.! Received By: