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`r RFRVIr..F RFLII IFCT r <br />Type of Business or Property <br />%�0.� E <br />'— -- <br />- ----- <br />FACILITY ID # <br />FAX # <br />cnuvo lJFl reVlseO U//1U/BB <br />SERVICE REP�UEST # <br />U <br />OWNER/OPERATOR <br />VV <br />F C �yL (t L L `C^J/,/ <br />y� <br />BILLING PART15- <br />FACILITY NAME <br />SITE ADDRESS5', <br />St Numbn <br />OirecGon <br />/ <br />Str O N.. <br />AN JOP..IU.:V Y <br />PUBLIC HEALTH SERVICES <br />Typo <br />S .0 <br />Mailing Address (If Different from Site Address) <br />i <br />CITYCC'�� <br />j CONTRACTOR'S SIGNATURE: <br />NATE ZIP 1520 <br />J <br />PHONE#13 <br />- `053 <br />r <br />APN# <br />LAND USE APPLICATION# <br />PHONE #Z <br />fxr. <br />1 <br />BOS DISTRICT <br />� <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR -'�� <br />f f M J t't (F BILLING PARTY ❑ <br />BUSINESS NAME C5 C0 <br />J <br />PHONE# EST. <br />' rJ <br />MAILING ADDRESS' Z I 'S <br />FAX # <br />CITY M O ry a y 1 -o STATE /fl/ ZIP <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, Standardp,'STh1E and FE L s <br />APPLICANT SIGNATURE: l DATE: <br />PROPERTY/BUSINESS OWNER OPERAT ft NAGER El OTHER AUTHORIZED AGENT <br />I/APP T is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />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. <br />I <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS ❑ <br />SPECIAL CONDITION(S) OF APPROVAL ❑ THER <br />❑ <br />a-hlx IVt t::tW f <br />4 <br />AN JOP..IU.:V Y <br />PUBLIC HEALTH SERVICES <br />_ <br />i <br />INSPECTOR'S SIGNATURE: <br />j CONTRACTOR'S SIGNATURE: <br />DATE: <br />APPROVED BY: <br />EMPLOYEE#: <br />( <br />DATE: of Ick <br />1 <br />ASsIGNEDTO: <br />� <br />EMPLOYEE#: <br />3139 <br />DATE. (OII qI t T <br />Date Service Completed (if already <br />completed): <br />SERVICE CODE: PIE: <br />Fee Amount:3 S`11 <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />4111 ft Its.- M D"ipy <br />