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�4 SERVICE REQUEST EHOO61SR revised 07/10i98 Type of Bu ' ess or Property1 1 FACILITY ID# SERVICE REQUEST# L) 7 OWNER OPERATOR 0l, "F(t LA o _ `l16� 776- 17 y 1 BILLING PARTY I FACILITY NAME �j p :a t,t}-fvl — Gl �U12 SITE ADDRESS 2(�G , ,, I Streal Numbw Wreetlon �� mel Name ��`J( 14� Type Suilep Mailing Address (If Different from Site Address) () 1 7"I CITY \, / {�, i y STATE CA ZIP rqo' CT PHONE#1 E><* APN# LAND USEAPPPP-LIICATION# U rCiq z PHONE#2 FxL BOS DISTRICT LOCATION CODE CONTRACTOR I SERVICE REQUESTOR REQUESTOR �� t`1 \ /� ,J V 1 ,7-\Y1L-IYCV�1 BILLING PARTY El BUSINESS NAME n r�L) � K 1' �C` oc 1C' �` K I PHONE# 3101 MAILING ADDRESS Exr JCL' l 2z k\buSCz� n ��, FAX# Dn CITY 'O ` STATE C4 ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project Or activity will be billed to me or my business as identified on this forth. I also certify that I have pre ared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stan s, � TE an FED s. APPLICANT SIGNATURE: DATE: G\— 3 r l� PROPERTY/BUSINESS OWNER l OPE ATOR/MA GER ❑ OTHER AUTHORIZED AGENT ❑ I(APPuc4viisn0tthe B1U1NGPARry proof ofautftonzabon to sign is required Title AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: <(� ✓ /r ,• I_� (i 1 COMMENTS ❑ SPECIAL CONDITIONS) OF APPROVAL OTHER ❑ ue - �/- 2 PAYMENT RECEIVEn Il-zv-�i� ' a� - �� Ong 0�,1•�l-s ��a�f ra dyrss='�1 / a _ eur [ N SLI/G I.(.1'llr'T d i Yyt tt P JOAgU1N I-QUNTY _7 l•t �Q G NMENigL HEAL7H DrVISInN INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: APPROVED EMPLOYEE#: DATE: r. ASSIGNEDTO: S ,I � ��' EMPLOYEE#: I g DATE: Date Service Completed (if already compfeted): SERVICE CODE: ,2-5— 1 P I E: Fee Amount: Amount Paid Payment Date f �Iq Payment Type Invoice# Check# 0 Received By: