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+ SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Properly MI^d-7(9-7(9 <br /> BILLING PARTY❑ <br /> OWNER OPERATOR <br /> FACILITY NAME ' C <br /> u ti <br /> (.�uU <br /> SITE ADDRESS Seew NVM Type Spnef <br /> $aMNUMrr Grectipn <br /> Mailing Address (lf Different tram Site Address) <br /> STATE ZIP <br /> Cm <br /> PHONE#T �T APN# LAND USE APPLICATION# <br /> �KJ <br /> 44,1— LOCATION CODE <br /> PHONE#2 �T BO$DISTRICT <br /> CONTRACTOR/SERVICE REOUESTOR <br /> SIWNG PARTY <br /> REQUESTOR <br /> V 4 <br /> PHONE# <br /> BUSINESS NAME S 2&_ <br /> C i J FAX# <br /> MAIDNG ADDRESS - 1 <br /> BILLING ACKNOWLEDGEMENT'. I,me undersgned property or business owner,operator or authorized agent of same,acimowledge that all sb and/or project specific <br /> Pvm:c HEALTH SERvCES ENvAcNMENTAL HEALTH DIVISION houM urges asso0aled wM m¢prolettar acdvity will be billed to me or my business as identified on mit form. <br /> I also cEroy that I nave preparec mis appllacon and that the work to be performed will be done in aanmance with all SAN JCAOUIN COUNTY Ordinance Codes,Standards.STATE and <br /> FEDERAL b1WS- /D / <br /> APPLICANT SIGNATURE: M1.f L r A DATE: /5A /h 1) <br /> PROPERTY I BUSINESS OMER ❑ OPERATOR/MANAGER ❑ 0IHERAUn10R2FDAGEM K <br /> I/AwrA.wra nR tlH Buwc PA.m.pmloYauMameon magncrswoed Till <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at me above she address,hereby authorize the release of <br /> any and all multi,geo(echni l data and/or enVlmnmentalitu a assessment information to m8 SAN JOAOUW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION BS Soon <br /> as If is andable and at me Same time it s provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C T <br /> S / t <br /> COMMENTS: <br /> r PAYMENT <br /> RECEIVED <br /> MAY - 2 2003 <br /> PUBLICO HEALTH SERVICES <br /> FNYRPI'l-rNTAL H€."ITH I"A" <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED fiY: A. <br /> EMPLOY�if: "'�'L -L DATE 5' L <br /> ASSIGNED TO: j, Ll�h EMPLOYEE#: DATE: <br /> Date Service Completed (if already wmpleted): SERVICE CODEP1EL '236 <br /> Fee Amount I Amount Paid _ Payment Date - - <br /> Payment Type I/ Invoice# Check# Vj <br /> ✓sio '' <br /> MAY 0 2 2003 <br /> ENVIRONMEN i HEALTH <br /> PERM;T/SERVICES <br />