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SERVICE REQUEST <br /> Type of Business or Property --- --7 <br /> FACILITY ID# SERVICE REQUEST# <br /> cow.n�A-��ma Y AR,v 5 K oo ;2 q3 f D <br /> I OWNER f OPERATOR <br /> BILLING PARTY <br /> C�'AC.trrlCr. �PcS P�17 C1.��TTLt�C.. C`ot�n�P�,,i•1.y <br /> FACILITY NAME <br /> PGFs r cE c 'rE�Z 5To ar=-cz�r.1 <br /> I Sri E ADDRESS <br /> i 4-o4O1�V �"i' LANE <br /> Street Humber oreC.ton Street Name Type Suite x <br /> Mailing Address (If Different from Site Address) <br /> (0 4 0 ) MAtL co0IF— <br /> CITY MPS � yGSLO STATE <ZJN zip q4 A 7-0 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> AS) T7 1,14 S — APt�I �rt'7-c�3p-o9 <br /> PHONE#2T- BOS DISTRICT LOCATION CODE <br /> z4 2- 14- <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY 1- <br /> BUSINESS NAME PHONE# Fxr. <br /> .5>MCyTCliA S�P�f tC S�P�'C1O►.5 ©TPM 1T �p .j .Lf•�C . 4564— 9333 <br /> MAILING <br /> 564— <br /> MAILING ADDRESS FAX# <br /> P'.0 , Std X 501 <br /> CITY 1EX6ce-rpo STATE CA Zip 9 520 1 I <br /> BILLING ACKNOWLEDGEMENT 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andfor project specific <br /> �ueuc HEALTH SERVICES ENVIRONMENTAL HEALTH DiVISION hourly charges associated with this project cr activity will be billed to me or my business as identifad on this term. <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 CGUNTY Ordinance:odes,Standards,STATE and <br /> FEDERAL1aw5. <br /> APPLICANT SIGNA E: DATE: <br /> PROPERTY/BUSINESS OWNER C OPERATOR/MANAGER F-7 OTHER AUTHORIZED AGENT <br /> If APPucANT rs not the&LuNc;papry proof of authorization to sign is required Ti N e <br /> 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 <br /> any and all resuits,geotechnical data andfor environmenlaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: pmi-eaR-r QF Two Ut'sC)EA C--1,V-.0QI,-L) IF-0 �'CORiLiNC-6-- <br /> COMMENTS: j <br /> j <br /> PAYMENT <br /> RECEIVED <br /> OCT 1 8 2000 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: A CONTRACTOR'S/IS--IIG�G--N,,AT1URE: <br /> l DATE: <br /> rirrnVvcv o r. I <br /> ASSIGNED TO: EMPLOYEE#: 0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P I E: <br /> ree Amount: r— Amount Paid S -7S3 I Payment Date <br /> Payment Type Invoice# Check# Received BY: <br /> FLC 80410(o(o I �,� <br />