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-- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'HGRtcu-L-vvR Nls"�1 ~coI�APN�2 5"I� lS <br /> OWNER l OPERATOR <br /> M4641AtL BILLJNG PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS2�3"Z 5C7v' <br /> StreerNumber IXrec>ion S1r�ttNhne <br /> TTOe S�ilr� <br /> Mailing Address (it Different from Site Address/ <br /> CrTY� G �JO Sb�� ��V 4 S RSA c> STATE zip 9'B <br /> 7 6 <br /> PHONE#t EXT. APN# LAND USE APPL1CATtON� <br /> (20y) 83�-493b ��5-toe, ©`7 <br /> PHONE 92 Ezr- Bas D1sTR€CT <br /> 4-g i-434 c >� P� If-� t OCATIOH CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> R!_QUESTOR /� <br /> yVAL71-=P, F , C XJRT1.5 BIt11NG PARTY <br /> $USIHESs NAME PHONE# err. <br /> 3� 34.6--44 <br /> MAILING ADDRESS a A S MLATTk f r,� �� FAX# `JIA <br /> CITY "t �--1�fl STATE 1`► <br /> CA, .Zlp 95-Z+6 <br /> BILLING ACKNOWLEDGEMENT: I, 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 DIMSION hourly charges associated with this projector activity will be billed tome cr my business as identified on this farm. <br /> I also certify that I have prepared this app€ication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY 01tinance Cortes.Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: O Z4 <br /> PROPERTY I BUSINESS OWNER Q OPERATOR I WNAGER 1] OTHER AUTHORIZED AGENT <br /> YArpl r�wr is rW Lha 139LM prootalauthoriraffon fo s;qn Is raquF 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 andlor environmentaftte assessment information to the SAN JOAQUIN COUNTY PUDLic HEALTH SERvICLS ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time itis provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> N <br /> PAYMEN-1 <br /> RECEIVED <br /> hUG 2 0X00 <br /> SAN JOAQUIN COUNT1 <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALT".��vl�luPt <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:, EMPLOYEE#; r :E: <br /> : <br /> A551GNED T0: EMPLOYEE#: 1 rj Q DATE: <br /> J 1 ✓Cl <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: . <br /> Fee Amount: ro Amount Paid g Payment Date�� 2-0 to <br /> Payment Type ✓ Invoice#' Check# ,4{ Received By` <br /> ` ' `��_L <br />