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SERVICE REQUEST we/ EH0061SR revised 07/10/98 Type of Business or Property FACILITY ID# SEV�_ICE REQUEST# boe sjeo+( - OWNER/OPERATOR Marfns' S BILLING PARTY P.S. FACILITY NAME SITEADDRESS LJC34, 5 Et " M:1qe goad 11530 Street NYmber Direction Street Nama Type Sube9 Mailing Address (if Different from Site Address) 'prn� CITY STATE zip _ $fix K{on C A. 1ysa t 9 PHONE#1 ECT APN# LAND USE APPLICATION# 9-31- ale -i PHONE#2 ErT BOS DISTRICT LOCATION CODE CONTRACTOR I SERVICE REQUESTOR REQUESTOR BILLING PARTY❑ rtC nt5'4Y VG+�1�^ BUSINESS NAME PHONE# EXT. P:Ie Ce kr e4 0^ A e.11- sqsLf MAILING ADDRESS FAx# Q•Qtior (4Y6) tiky ' S%5 CITY SIL c.raa •K as STATE zip 1542 C-4-Is BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific 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. 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 FE L laws. APPLICANT SIGNATURE: _ DATE: V 00c q 4 PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ I£APPUCANT is not the BILLING PARTY 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 environmentallsite 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: COMMENTS ❑ SPECIAL CONDrrioN(s)OF APPROVAL❑ OTHER ❑ PAYMFNT RECEIVEO DEC 14 1998 AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: APPROVED : EMPLOYEE#: f DATE: - ASSIGNED TO: EMPLOYEE#: ©� DATE: fid" 4 Date Service ompleted I f already completed): SERVICE CODE: PIE: 0 Fee Amount: �4— Amount Paid � � Payment Date Payment Type Invoice# Check# �j ,,�1, Received By: