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CCD%11rC ocni1rnt <br />Type of Business or Property <br />FACILITY Ig l v <br />SERVICE REQUEST # <br />PHONE# Ext. <br />OWNER /OPERATOR <br />.� - l 7 n <br />BILLING PARTY 0 <br />FACILITY NAME <br />SITE ADDRESS <br />Street Numbv BtrFction <br />V � l ` � O �M <br />�Ty <br />Mailing Address (If Different from Site Address) <br />N�� <br />Suil� <br />CRY L4-0 l� <br />�� jsL� ZIP <br />STATE CH <br />PHONE #1 �• <br />( <br />APN # <br />LAND USE APPLIcA/ TIION # <br />PHONE #2 EXT. <br />BOS.DISTRICT <br />LOCATION CODE <br />iR•a ncnwr.�w�x�•nw�r� �uus�uni <br />REQUESTOR ll <br />� n � Ery c� £2 Sa 1�1 <br />BILLING PARTY 0 <br />BUSINESS NAME L -- C S s v�'e. ES <br />PHONE# Ext. <br />.� - l 7 n <br />MAILING ADDRESS <br />FAX # <br />,CITY F� = SN 0 <br />STATE C- ,.q ZIP <br />9372 <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 />PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourty 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 />PPUCANT SIGNATURE: "Z '� DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHERAUTHORIZEDAGENT SE2V L'� /C/y <br />IfAPPuc wr is not rho ftt-m Paary Proof of authodratlon 10 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 environmental/sile assessment information to the SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />APR 3 2001 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br />APPROVED 13Y.. _per EMPLOYEE#: DATE: <br />ASSIGNED T0: L •�J EMPLOYEE #: C� L? DATE: <br />Date Service Complete (if already completed): SERVICECODE: ! <br />VII PIE:.34� <br />Fee Amount:C ' Amount Paid <br />Payment Date <br />Payment Type Invoice 4' Check # <br />_ — Received By: <br />E <br />