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SERVICE REQUEST EHOO61 SR revised 07/1 n/9R Type of Business or Propel, FACILITY ID # BUSINESS NAME a (_.. I�t vin% t �1��. + SERVICE RE UES # Qy` lD rOWNERI OPERATOR St V\ �\ dY\ BILLING PARTY ❑ FACILITY NAME IJ -`— G-�4 _ xl \ & fy arI CITY �E d --c S+ -t> SITE ADDRESS !0 L4[ LAJ Q � LJ PA EMPLOYEE #: - DATE: Street Numher Direction Street Name DATE: Type Suite 0 Mailing Address (If Different from Site Address) Fee Amount: 15� CITY Tra C STATE„ ziS 3. ` Is�o PHONE #1 EXT. poft)$33-3HI� APN # LAND USE APPLICATION # PHONE #2T• BOS DISTRICT Received y: LOCATION CODE oa S 63 CONTRACTOR / SERVICE REQUESTOR REQUESTOR C Lf> r � 1,AJ (1 BILLING PARTY BUSINESS NAME a (_.. I�t vin% t �1��. + COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ PHONE#S3 O O EXT 6 MAILING ADDRESS�3 --J ' \ t -� y�1 t•- e_ FAX# 1..0 EC 11 1998 — - CITY �E d --c S+ -t> STATE Com- ZIP 9 53 5,2 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLICIHEALTH SERVICiES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity Will be billed t0 me or my business as l ied on this for I also certify that I have pr red this Ordinance Codes, Standa ATE.an APPLICANT SIGNATURE: PROPERTY / BUSINESS and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY ❑ OPERATOR/ MANAGER ❑ If APPLICANT Is not the BILLING PARTY DATE: I 1 / I c-' OTHER AUTHORIZED AGEN ❑ 0o a� uf5Ufff—a !on 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 environmental/site 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: �Z�t I COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER ❑ •� f EC 11 1998 — - AR JOAQUIN C PUBLIC HEALTH VUNTY ENVIR NMENTAL HEn ERVICE INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: APPROVED BY: r \ EMPLOYEE #: - DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 3 P / E. , 3d Fee Amount: 15� Amount Paid $• Z Payment Date Payment Type Invoice # Check # Received y: