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SERVICE REQUEST <br /> Type of Business or Property FACILITY IDR SERVICE REQUEST# <br /> 5aO36711 <br /> OWNER OPERATOR - BILLING PARTY❑ <br /> 542o/ri <br /> FAOILrTY NAME T 4 j�UGeuJG <br /> SrTE ADDRESS jj 396N' f-f�GrfklfYy 99 <br /> soecxumov mr.non smnxm. rm• svn.e <br /> Mailing Address (If Different from Site Address) <br /> CffY �.� {.- / / STATE mil ZIP <br /> •T <br /> PHONE#'I TV`'�/VrvEXT. ( APN# LAND USE APPPuu"cxnoN 9 „I //'� <br /> (zaq q31 - �c�o o5ri- Nib -o3 0 - ob� d-� 3---G <br /> 9-3t - <br /> PHONE#2 Ear. BOS 0171CT - LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> lUlrC �y <br /> BUSINESS NAME T?/(- .-v.� /1'�U�O P70q# 37 ¢-66 t3 <br /> MAILING ADDRESS /' , FAX'# <br /> -P• o. aox LI SO xG 3 T - o-7 23 <br /> CITY L'&01 STATE -/'4 <br /> ZIP -15-2-4- <br /> BILLING <br /> 1rlABILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project spee&,c <br /> Pusuc HEALTH SERVICES EwRCNUENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on ths form. <br /> I also certify that I have prepared this appfic bon and that the work to be performed will be done in accordance with an SAN JOAOuIN COUNrY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> � - 2 , � ¢ <br /> APPLICAM SIGNATURE' DATE <br /> PROPER TY I BUSINESS IFN ❑ OPERATOR/4 i ❑ OTHER Atmommo AGENT ❑ <br /> I/APvt,tWris rd de Df!meP.wry pool olaet/ramCon to ign is requikad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applictide.I,the owneror operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or emimnmentaysite assessment information to the SAN JOAQUIN COUNTY PuaUC HEALTH SEAVIcEs ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same Noe it is provided tome or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> R 204 <br /> JPN3MC� <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: E1PL_YEE#'. C DATE. <br /> ASSIGNEDTO: .. Q EE#: DATE: - v <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> FeeAmount ��p Amount Paid j$ ��� L`L?i:. Payment Date <br /> Payment TypCheck# QS -2--- <br /> - Received By: 5' <br /> - ,+ <br />