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A , 1 SERVICE REQUEST EH0061SR revised 09/04/98 Type of Business or Property c5t"F- R1cs I nEl�tc-� AND FACILITY ID# M, t SERVICE RE}UEW,# I OWNER/OPERATOR BILLING PARTY❑ F' O FACILITY NAME (SAt✓�� AS n--NER Jc:PEF_ATot-) SITE ADDRESS 31 7 to<�'T" 11�1Q[�17S�N '�O/ Street Number Direction sbid Name Type Suite# Mailing Address (If Different from Site Address) CITY AC_AMF'� STATE r zip C��Z�O PHONE#1 EXT- APN# LAND USE APPLICATION# r-y (D05-CA<n-- i 2 PHONE#2 ET- BOS DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTOR WAL CURT(�" BILLING PARTY BUSINESS NAME PHONE# E.T. C Oy 1 U I cafy) MAILING ADDRESS FAX# 4-18 MA-M'keW pi.AZ-A LCRY Lo-oI STATE GAS zip 95L4-o BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o6Mthoriz anent 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 form. 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 FEDERAL laws. APPLICANT SIGNATURE: �� DATE: (It--t9—96 -- PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ ^If APPLICANT is not the BILLING PAR Tv proof of authorization to sign is required Title 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 any and all results, geotechnical data and/or environmentallsite 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. TYPEOF SERVICE REQUESTED: REYtt;� 1L `.i�':TA��L1-fel 3TUa�f�'D 1Eb tl-•1 _ J. m`.;- 84-2:7 COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ RECEI F-F %ov 191998 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1H nIVIS --- ......---....--- INSPECTOR'S SIGNATUR CONTRACTOR'S SIGNATURE: DATE: APPROVED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: t 1 DATE: ' Date Service Completed (if already completed): SERVICE CODE: a P 1 E: Fee Amount: Amount Paid Payment Date l Payment Type Invoice# Check# Feceiverl By: