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SERVICE REQUEST <br /> F /of B'.siness or Property FACILITY ID# <br /> .'`f r SERVICE REQUEST# <br /> y OWNERIOPERATGR <br /> �� Bu I L 1 V S —, f B UNG PAR <br /> FACILITY NAME V �'^ ` �Q� L— <br /> SFTEADDRESS � 9�3 •� F <br /> Stre.t Numb.r DirecCon V v . J u <br /> Mailing Address (If Different from Site Address) JJ TYPE sate a <br /> CITY <br /> STATE ZIP <br /> 952-42- <br /> PHONE#1 E-- APN# <br /> LAND USE APPLICATION# <br /> PHONE#2, it (°� I E�cr <br /> G�t�1VC l 1 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR ^ <br /> l/�,--1//1 31 t Bulu)c PARTY 0 <br /> E E PA4M54 , ,5 <br /> PHONE# _MAI <br /> FAx# <br /> CfTYSTATF� � zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> 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 form. <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 Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANT SIGNATURE , <br /> DATE: I I <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER )V, On HER AUTHORIZED AGENTMATD <br /> If APvuc wr is not the ar nnry proof of authorization to sign 7s rvquirvd T i t l o <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 and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALnI SERV10Es ENVIRONMENTAL HEALTH DIVISION 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: ✓7 P� T-CS kQ I -(7"- fr ""),1 --il�od�n�` a 4fZ. �SIt ad 4) � <br /> •/3 • s9� zL NoT ry ��1 <br /> //__ ✓ l✓ �uct'e X71 J�4t1 <br /> �����PY�i✓j�G L+ /t���! �/1�i�✓���' `fY�! j� l <br /> LGa's %cG ✓✓mss ° REC d <br /> r 50 6r v,1 ;)�Ij G.�G�� /� s 64GJ>���.��c /W��t� JAN 13"2000 <br /> 1r/ G✓ 7 -d` Lr'�'G�, / ��h/' / fD��' Ur cI 'f7/ 51_ SAN JOAQUIN COUN,Y <br /> PUBLIC HEALTH SEFIVICES <br /> � f9Yil�,i ENVIRONMENTAL HEALTH 0IVISIOr. <br /> P- <br /> INSC OR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. Q , EMPLOYEE#: Q DATE: <br /> ASSIGNED TO: WW <br /> EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: O( PIE: <br /> Fee Amount: Amount Paid r Payment Date <br /> Payment Type Invoice#' Check# <br /> Received By: <br />