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If - 8 SERVICE REQUEST Type of Business or Property FACILITY ID # BILUNG PARTY SERVICE REQUEST # BUSINESS NAME PAYMENT OWNER I OPERATOR BILLING PARTY i i FACILITY NAME MAR 152000 MAILING ADDRESS SITE ADO ESS FAX # ENVIRONMENTAL HEALTH DIVISION INSPECTOR'S SIGNATURE: y- 0 9 % "e, � _ Street Numb. Ofact.., STATE ZIP strut Name Type Suite X Mailing Address (If Different from Site Address) EYPLOYSE C) I Its " tr✓�- DATE: CITY STATE ZIP SERVICE CODE: rAr 9 -:F,;, � PHONE #1 En. APN #OS Amount Paid U U LAND USE APPUCATION # ("1j) _ oq-, - Invoice # Check # G� �� PHONE #2 EXT. BICT DISTR LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR / BILUNG PARTY -D p � e S BUSINESS NAME PAYMENT PHONE #• RECEIVE© MAR 152000 MAILING ADDRESS SAN,'OAQUIN COUNTY PUBUC HEALTH SERVICES FAX # ENVIRONMENTAL HEALTH DIVISION INSPECTOR'S SIGNATURE: y- 0 9 Circ STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION houdy charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed wdl be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. // APPLICANT SIGNATURE: G�},l, f e" S B ^ �^^S .� DATE: 3 r PROPERTY / BUSINESS OWNER OPERATOR / MANAGER Cl OTHER AUTHORIZED AGENT ❑ If APRr.mT is not the B9.Lm PAary proof of audxwtudon to sign is required rifle 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 any and all results, geotechnical data and/or envimnmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTii SERVICES ENVIRONhENRAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: / j - t 64t �� -D p � e S PAYMENT RECEIVE© MAR 152000 SAN,'OAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE. APPROVED BY: ^ C EvPLCYat �� I DATE \ ASSIGNED TO: - EYPLOYSE C) I DATE: Date Service Completed (if already completed): SERVICE CODE: S P I E: Fee Amount: Amount Paid U U Payment Date Payment Type ✓ Invoice # Check # G� �� Received By: vt) �v-