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t <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITEADDRESS ("� <br /> 7 Street Number Direction Street Name 7—Type Suite 0 <br /> Mailing Address (If Different from Site Address) <br /> CITY / ' • / _ STATE zip <br /> PHONE#1 (/ EX*. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> CITY L/Ai D r STATE C?SZ-3 69 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 w t performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. 1 <br /> PPUCANTSIGNATURE: I / DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPm%vris not the Buw,,Parte:proof of authorization to sign is required Title <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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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: r� <br /> COMMENTS: <br /> 11117 heS R�.vi-�J� �.�t�,�vj/� <br /> NOV 15 Ima <br /> SAN JOAQUIN COuK.y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: -1 <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: � ,(�� EMPLOYEE#: lr�•�//"/� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3( P/E: ' <br /> Fee Amount: . QU_- Amount Paid Payment Date A ll <br /> Payment Type Invoice 9' Check# C Received y: <br />