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SERVICE REQUEST Type of Business or Property FAcgLrrY ID# SERVICE REQUEST# S(2Oa �-j1&Col NER ERATOR _ - BILLING R@7 FACILrrY NAME M 13 SREr7isA6N44` ao-l�INumbr 04ection ShMNNm Type SvNr/ Mailing Address (If Different from Site Address) CITY STATE ZIP -t–ert GA_ PHONE#1 APN# LAND USE APPLICATION# PHONE#2 FM. BOS,DtsTRTcr LowioN CODE' CONTRACTOR I SERVICE REOUESTOR REQUESTOR r� BILLING PARTY❑ BUSINESS NAME PHONE# Tn• MAI `,DRESS SoB FAX# Ev T STAT ZIP c� Cid- r�d ir BILLING ACKNOWLEDGe" 2 ed property or business owner,operator or authorized agent of same,acknowledge that an site and/or project specific PUBLIC HEAL jMRON hourly charges associated with this project or activity w9 be billed to me or my business as identified on this formI also certify thatat donned will be d e in a nce with an SAN JOAQUIN CcI Ordinance Codes,Standards.STATE and FEDERAL laws. 27 i APPLICANT SIGRATU DATE: PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IIAaarcwT is neat BUM Puny.Proof ofsuthodzadon to sign is requLsd Title AUTHORIZATION TO RELEASE INFORMATION:When applicable.1,the owner or operator of the property bated at the above site address,hereby authorize the release of any and all results,geotechnical data and/or envinanmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E1mRONMEHTAL HEALTH DIVIGIDN as soon as it Is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: I COMMENTS: PAYMEN RECEIVED MAR 12 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED BY:. EMPLOYEE#: '1 DATE: ASSIGNED TO: EMPLOYEE 9: Vw DATE: Date Service Completed (if alr y)completed): SERVICE CODE: `1j PIE: Z Fee Amount: l t2— Amount Paid Payment Date PaymenlType Invoice 9' Check# Received By: