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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> TTC v� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SEb�R55 ri' eN� a'P"�-,p <br /> HOME or M ING ADDRESS (If Different from Site Address) l� <br /> 7 3 tb <br /> CITY ' STATE ci ZIPL <br /> U f - <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (q{ 6) � �2Z 1 c13 020 -32 <br /> PHONE#Z Ems' BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKN0_M1EVt_-r MT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I:Aso certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: o� DATE: <br /> PROPERTY/BUSINESS OWNER _ —OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ffAPPL/CANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: N lbkic <br /> COMMENTS: <br /> APPROVEDBY: EMPLOYEEM 032— DATE: <br /> ASSIGNED TO: �5� I�e n (�. EMPLOYEE M J�IJL Lp DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: +45 6-0 Amount Paid Y41c/5 O0 Payment Date tl d <br /> Payment Type — Receipt# Check# Recelved By: <br /> EHD 48-01-010 <br /> 7/1/1999 <br />