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- �jMdk`a- <br /> ' SERVICE REQUEST ~ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RE S IDEr%,/ L 1 66 Z 7 <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> BO- OI>I <br /> FACILITY NAME <br /> U ESy SNL <br /> SITE ADDRESS /k 4 A/(f <br /> 31,90 su.dmv w Wec9an str..tNNm T�/. SNI.I <br /> Mailing Address (If Different from Site Address) <br /> Crtv STATE CA zip f 3 <br /> RAc 7& <br /> PHONE91 Ea. APN# LAID USE APPLICATION# <br /> AvoT lssuED FT <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PAR7y <br /> U�/ Ch/�SNE <br /> BusuREss NAme ` J� E E (ZC PHONE# <br /> MAILING ADDRESS v FAX#' <br /> CITY STATE , <br /> .^ ZIP <br /> "A <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge Nal an site and/or project specific <br /> PUBLIC HEALTH SERVICES ENviRONMENTAL HEALTH DAnsIO.N hourly charges associated with this projector activity will be billed to me or my business u identified on this form. <br /> I also oodify that I have prepared this tion and Nat ork to be performed will be done in acwrdaOM with alSAN JOAQUIN COUNTY Ordinance Codes,Standard STATE and <br /> FEDERAL laws. <br /> APPucAxTSIGRATURE: DATE. <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER OCHER AUTHORIZED AGENT /'�j�(/ ' <br /> itAAYsrwrBot Un rid 0UMEvm � <br /> :PrvolofIuthsdon to slpn is reauI'Md ` Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the pro perry lomlod at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentailsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it Is available and at Ne same time it Is provided to me or Try representative. <br /> TYPE OF SERVICE REQUESTED: <br /> �RcE At/D SKRF/{c� r✓TAAz'y/N,Q roi✓R�PoRr /� E <br /> COMMENTS: pp <br /> 1gV-a/ FL�GI�Gt/�c �D Itch. <br /> PAYMENT <br /> /6/ � RECEIVED <br /> 3„ _ yFll . OCT 1 - 2001 <br /> UNTY <br /> PUBLICC HEALTH SEJOAQUIN RVICES <br /> ENVIRONMENTAL HEALTH DIVISIOt. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVER BY:. / EMPLOYEE 9: ql!5 /7 DATE: <br /> -ASSIGNED TO: EMPLOYEE III: / DATE: <br /> Date Service Completed (if already completed): SERVICECODE: ? J.�� P I E: z O <br /> Fee Amount: o l 7ro Amount Paid _ - : Payment Date <br /> Payment Type l 0 Invoice#' Check# -� <br /> �a Received By: � , � <br />