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S SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE <br /> As FDO S� CXR <br /> OWNER OPERATOR BILUNG PAR <br /> FACILITY NAME <br /> ((f/�r�'� r�I Numbw drection SIrMNM/ �T§[� Svll./ <br /> Mailing Address (If Ditterent from Site Address) <br /> CRY a STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> -©3cn <br /> PHONE 92 EXT. BOS DISTRIci - LOCATpN CODC <br /> ro <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BLLUNG PARTY <br /> � 1 <br /> BUSINESS NAM PHONE# FM. <br /> MAILING ADDRESS FAX <br /> T .T d GYs z z2 <br /> CITYDocow E <br /> /RA <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all silo and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL.HEALTH DIVISION hourly Charges associated with this project or activity will be billed tomo or my business as identified on this form. <br /> I also certify that I have prepared this appfNation and that the workP be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standartls,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: /5-3-00 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER OTHERAUTHOrUIED AGENT ❑ <br /> I/ArPrxwrisratllaflunc PAnrY procfurauthorindon to sign is mulmd rifle <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 environmentallsile assessment Information to the SAN JOAOUIN COUNTY PUauc HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon <br /> as it is available and at the same Ume it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> l�Su� <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> OCT - 3 2000 <br /> • SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIG TUBE: <br /> APPROVED BYL EMPLOYEE#: / DATE: L) 1 <br /> .ASSIGNED TO: 3 v <br /> EMPLOYEE#: DATE: <br /> :Date Service Completed (if already completed): SExveECooE: Z Y� <br /> PIE: 0 ' <br /> Fee Amount: Amount Paid Payment Date ® 3 (/z) <br /> Payment Type Invoice#' Check# <br /> J� � C1 eccived <br />