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Z SERVICE REQUEST Type of Business or Property > FACILITY ID # SERVIC� REQU T # �)` (1f C7-k /V�V FAX # M ILING ADDRF4S OWNER I OPERATOR Vol - BILLING ARTY! FACI V A E °�A p -PAYMENT C` ECE' D C FEB 10 1999 SITE ADDRESS S4"HE.UUHr+Sl`URI,VNI,rY SENVIHONAEM7N`HEALi H UIViS10N INSPECTOR'S SIGNATURE: Z Street Number Direction Street Name "PLOYEE t Type Suite # Mailing Address (If Different from Site Address) CITY ST511 r� zip DATE: PHONE #1 ExT• APN # LAND USE APPLICATION # rLq) bs - SERVICE CODE: PHONE #2 ExT• Fee Amount: i 1 ' C> BOS DISTRICT Payment Date LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR BILLING PARTY ❑ > INEssNNAAMrEE � PHONE ` P EXT. �)` (1f C7-k /V�V FAX # M ILING ADDRF4S Vol - CITY �, f ?S;A IP BILLING ACKNOWLEDGEMENT: I, the unders. PUBLIC HEALTH SERVICES ENVIRONMENT HEALTH DNI I also certify that I have pare is a lication and FEDERAL OWS. 11 t\ APPLICANT d property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific I hourly charges associated with this project or activity will be billed to me or my business as identified on this form. J1 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and DATE: Z— /0— e f PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the Bi uNG PAtry proof of authorization to sign is required Title 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 any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: v � > COMMENTS: p -PAYMENT C` ECE' D FEB 10 1999 S4"HE.UUHr+Sl`URI,VNI,rY SENVIHONAEM7N`HEALi H UIViS10N INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED BY: 1 "PLOYEE t DATE: 1 ASSIGNED T0: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: Fee Amount: i 1 ' C> Amount Paid 3 �/" LIV Payment Date p 2 7 rPayment Type Invoice # Check # � (D o O Received By: