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SERVICE REQUEST <br />Type of Business or Property <br />Wk w <br />FACILITY ID # <br />DU <br />SERVICE REQUEST # <br />PAYMENT <br />PHONE # 'XT* <br />`' �Ib l - � <br />MAILING ADDRESS � � � <br />� �, C <br />��_ L�� r- <br />OWNER OPERATOR <br />CITY " C%Q <br />BILLING PARTY 0 <br />0 �r0 Cid <br />8AN JOAQUIN COUNTY <br />FACILITY NAME <br />PUBLIC HEALTH SERVICES <br />FtMR NMFNAL HFALTH <br />DIVISION <br />SrrE ADDRESS <br />CONTRACTOR'S SIGNATURE: <br />n <br />APPROVED BY:.C� <br />EMPLOYEE #: C <br />1 -- Street Nuft4r <br />o � on <br />\ 1 L1 <br />Sb W N3n4 CN C 1�� C <br />Type <br />SuRs <br />Mailing Address (If Different from Site Address) <br />SERVICE CODE:P <br />I E: Z <br />Fee Amount: 7 <br />Amount Paid ��—� _ <br />C <br />CfTY , — <br />�j <br />STATE Q- (" zip! ���� 's_o <br />PHONE #1 ExT•APN <br /># <br />Received By: �� <br />LAND USE APPLICATION # <br />PHONE #2 EXT•BOS <br />DISTRICT' LOCATION CODE <br />" �2 -16 \ yC <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTOR <br />JeC' <br />Wk w <br />BLLING PARTY) <br />BUSINESS NAME <br />�o� t`c.Lrvt; � <br />PAYMENT <br />PHONE # 'XT* <br />`' �Ib l - � <br />MAILING ADDRESS � � � <br />� �, C <br />��_ L�� r- <br />FAX # — <br />'-4 61 3�2. <br />CITY " C%Q <br />STATE (l L zip 0,3— <br />BILLING ACKNOWLEDGEMENT: 1, the undersgned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DnnSION hourly charges associated with this projector activity will be billed to me or my business as identified on this form. <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 COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: V <br />DATE: In — 3 — O 2— <br />PROPERTY/ BUSINESSFN I ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 0 <br />I(Avptr�axr is not the & i r c P wTy proof of authorization to slpn Is mgukvd 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 environmentaVsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIs10N 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: j , — <br />COMMENTS: <br />PAYMENT <br />REC'EIVED <br />JUN 520p <br />8AN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />FtMR NMFNAL HFALTH <br />DIVISION <br />INSPECTORS SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />n <br />APPROVED BY:.C� <br />EMPLOYEE #: C <br />DATE: /_ <br />U! / V o <br />ASSIGNEDTO: l <br />_ <br />EMPLOYEE#: -35 C) <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:P <br />I E: Z <br />Fee Amount: 7 <br />Amount Paid ��—� _ <br />Payment Date �/S / <br />Payment Type Invoice #' <br />Check # 5q(" <br />Received By: �� <br />