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f SERVICE REQUEST ' <br /> Typ o Business o roperty,1 �► lJ FACILITY ID# SERVICE REQUEST# <br /> OYYNER4 OPERAT &'�4r�tma- � c BILLING PARTY❑ <br /> Facltm NAME / C <br /> SITE ADDRESS <br /> r qStmtNumbs ettian StrMNMe <br /> Mailing Addr ss (If D' event from Siteddress) <br /> �Y'� iiL <br /> CITY ) ST <br /> T� ZIP <br /> l/ 9o�/ <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (23 4( 5- 3qc) / <br /> PHONE#2 xt. BOS:DISTRfc'T LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> — LAhu--," I'_6(w) 1-\ <br /> BUSINESS NAME 0, PHONE# EXT. <br /> MAILING ADORE r/ <br /> ow <br /> 1 FAX ^GT <br /> Cent a11-ISTATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prep this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. JJ <br /> APPLICANT SIGNATURE: aj�!= DATE: !� <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IIAvarc wr is not the H urc Pure proof of authorhadon to sign is required Title <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 results,geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EwiRONMENTAL HEALTH DMSIoN 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: �- Yi1/�'/ ✓W <br /> COMMENTS'. <br /> PAYMENT <br /> RECEIVED <br /> )EG 21I <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH 01VISIcI.N <br /> INSPECTOR'S SIGNATURE=,: ' CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE-#: /` �1 ( DATE' <br /> ASSIGNED TO: EMPLOYEE#: `�xJJ IIJJ� DATE: <br /> Date Service Completed (if a ready com leted): SERVICECODE: l PIE: <br /> Fee Amount: TA-mount Paid -L _ Payment Date j 1 <br /> Payment Type Invoice#' Check 4 l r,C''4 Received�By:: <br />