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SERVICE REQUEST <br /> Type of$Ds,aess or Property FACILITY ID# SERVICE REQUEST# <br /> FA <br /> OWNER OPERATOR <br /> BtLtING PARTY 0 <br /> FACILfiY NAME <br /> SITE ADDRESS ] I <br /> �SVee1 Number OlrcEoon <br /> MNxm �YP� Svrlr/ <br /> Mailing Address (If Different from Site Address) <br /> Crit STATE zip <br /> PHONE#1 (� APN# LAND USE APPLICATION# <br /> i ) <br /> PHONE 92 Err. 80S.Dt5TR1cT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RSINE <br /> BtuING PARTY Cr <br /> BUSINESS <br /> 7L IIL-.?C PHONE# ZG Ezr. <br /> S FAXatzo <br /> - 1. STATE � ZIPACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUpUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or act vity will be billed to me or my business as identified on thls form. <br /> I also certify that I have aced this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Sfandarcts,STATE and <br /> FEDERAL laws, ll —( <br /> APPLICANT SIGR)&I <br /> PROPERTY I BUSINESS OWNER D OPERATOR!MANAGER C OTHER AuTRORlzEDAGENT D <br /> 1tAPft.r-wrisnciL)e8uwGpAg Pmofolaurhorisatfontoslpnisrequirvd Tifla <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the owner or operator cf the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentausite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONISION as soon <br /> as it is ava lab;c and at the same time it is provided to me or my representative. <br /> TYPE Or SERVICE REQUESTED: <br /> COMMENTS: <br /> D <br /> JAN 2 5 200, <br /> SAiv JOAQGIN <br /> ENVIR0Nv[--NTACTN FRU NN <br /> �t NFR[rii f�rb'lSruN <br /> INSPECTOR'S SIGNATURE: CCNTRACTOR`S SIGNATURE:. <br /> APPROVED BY:. �� IP., r, EMPLOYEE 9: �0 ! DATE: <br /> ASSIGNED TO: EMPLOYEES. !� L � DATE: <br /> Date Service Co pleted (if already completed): <br /> SERVQ CEC10DE: PSE: -ZC? <br /> Fee Amount: ( t t?` Amount.Pali r Payment Date 1 <br /> 40 <br /> �ISS o <br /> LPa�yrnent Type invoice#' Cheek ft S <br /> 3 � Received By: <br />