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SERVICE REQUEST } <br /> T�pc of Business or Property FACILITY 10 9 <br /> SERVICE REQUEST# <br /> OWNERIOPERATOR �3 <br /> ' <br /> BILUNG PAR ` <br /> FAciLrTy NAME <br /> SITE ADDRESSf /� <br /> • `+ 1 Steel Numh•r IXrettian h T� 20 ofI a� C.J I <br /> Mailing Address (!f Different from Site Address) SVHIName J Type SulI <br /> a3 Sat�c� :�,coca <br /> CrtY ons�( <br /> STATE 1 Iq zip <br /> "( 3 33G <br /> PHONE#i Exy. APN# LAND USE AppucnoN# <br /> PHONE#2 BOS DlSTRfCT <br /> LOCAT30Ff CODE <br /> REQUESTOR <br /> CONTRACTOR 1 SERVICE REQUESTOR l <br /> ' �} �} <br /> BO-UNG PARTY 0 <br /> BUSINEss NAME f'_ <br /> S C)V�. CA S k:)l PHONE , <br /> MA l-1 ADDRESS <br /> 0� [ 3� 7D / <br /> bu sio� CV-) FAX <br /> CITY <br /> �Q 3 <br /> C ol/� f STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigrrod property or business owner, operator or authorized agent of same, acknowledge that all site andfor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION hourly charges associated with this projector activity,will be billed to me of my business as iidontifed on this farm. <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 Ordinanctt Codes,Sfarrdards,STATE and <br /> FEDERAL.laws. <br /> APPLICANT SIGNATURE. <br /> f)ATE: <br /> PROPERTY I BUSINESS OWNER OPERATORIMANAGER 0 OTHER AUTHORIZE4AGENT <br /> fJ <br /> lfArm r wr is nor tf>o 0_Ut c PARrY.proof of aulhodi2ilon fa sign is mairvd rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1,the owner or operator of the property kxatod at the above site address,hereby authorise the release of <br /> any and all results,geotechnical data andfor environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1_NVIRONMENTAL HEALTH DMSION 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 /> PAYM ENT <br /> RECEIVED <br /> FEB 2 7 2001 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC ENVIRONMENTAL(LHEAITH DIVSIl <br /> TH SERViCES <br /> INSPECTOR'S SIGNATURE: NATURE:: [ <br /> APPROVED 4Y:. CONTRACTOR'S SIG <br /> EMPLOYEE : !)l <br /> �t DATE. <br /> ASSIGNED 7O: EMPLOYEE#: <br /> 1J v`7 'DATE: <br /> Date Service Completed if already completed): 94 <br /> •L -Q j SERVICECOUE: P 1 E:. <br /> Fee Amount: <br /> Amount Paid �� � . Payment Date <br /> Payment.T . e 1`? C7 I Q r <br /> Type invoice>r' Check� <br /> .L� R�ccived By{ <br />