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%?,6/27/2E01 13:57 2094683 FIFTH FLOOR . PAGE 05 <br /> w <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUTY 10 R SERVICE REQUEST" <br /> Z <br /> BILLING PARTY D <br /> OWNER I OPERATOR <br /> QU1KSiZ�P MA-�L.,�C�rS X132 <br /> FACILrrY NAME V I ICS�A M E73 13 <br /> SimAoDRESS 335 W N 1KC-� `Aal <br /> sre�e Mgm6er ot�,G.n saws�. tra. s�a <br /> Mailing Address (1f Different From Site Address) <br /> C; STATE Z>p <br /> PHOYERl APN,'l: <br /> LAN USE APPLICATION` <br /> PHON£92 SOS DLSTRICr L OCATiOH.Co4€:. <br /> CONTRACTOR SERVICE REOt0 TOR <br /> R£QUE5TOR BILLING PARTY Cl <br /> Pi3tlE—�.A �c�2Li�5 <br /> BUSINESS NAME RHONE# <br /> 1 Rt4AI&L t= b✓Vii20n/�fEnr'7 rl L , /lJC . &S- J'qO -'JU 2 6 <br /> UNG ADDRESS FAX M <br /> MAf <br /> �525 j7/• t3u��K ,8 L vD pq�- S410 -&,9-29 <br /> Crrr $ct,e f3Aal K STATE OA Zip q/ 5'05" <br /> 8ILLING ACKNOWLEDGEMENT,I,the undersigned property or business owner,operator or authorized agent of same,advowledge that all site and/or project spec Cw <br /> PusuC HEALTH SgAv1GES EM/=MENTAL HEALTH OLVISION hourly charges associated wilt+ftS praject oT acSk will be billed to me or my business as identified an this ami. <br /> I also certify that 1 have prepar*d this applica foe and that the work to be peribaned Nig be done in a=rdance with all SAN JaAOuI.N COUNTY Ordinance Godes,Standards.STATE and <br /> Fi:bER tL laW'a. <br /> Z li DATE' <br /> APPUr_w SIGNATURE: —/ <br /> FRO'ERtY i BUSINESS OWNER 0 OPERATOR 1 MANAGER 13 OTNOt AUTHOkffID AGFJ' tl Q� <br /> if APw.raYrisnae8uauncra8�prWd2UdXW&;aVbe1 tasi�n;sTitle <br /> AUTHORIZAT ONTO REL.FASE INFORMATION:When applicable,1,the owner or operator of the property Jocatad at the above site address,hereby authariW the release of <br /> any and all results,geotechnical data andlor envlranmeAMVSite assessment Information to the SAN JOAGUIN COUNTY PUSUC HEA4TH SERVIM ENVIRONMENTAL HEALTH flrvtSlaN as soon <br /> as 4 is available and at the same time it i5 provided to me or my represerrtahve. <br /> TYpE OF SEFrACE RmuEsTw-. --r— 7— <br /> COMMENTS., ,nJ T Bit. �/t PAYMEN" <br /> RECEIVEF'' <br /> UG 0 <br /> , 'L <br /> SAN JOAQUIN COUNT <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMFNTAI HPAI_TH 0IV!?,1iN <br /> INSPECTOR'S SIGNATURE: CONTR4=R'S SIGNATURE' <br /> APPROVED BY: �!� � fStPtA � 10� 0® DATA <br /> ASstGNmTo: EMPLOYE=_#: 0 v � DAA <br /> Date Service Completed Cif already comp! Sezvtcs Goae P 1 E �3 i <br /> Fee Amount: 61 Amount Paid �b Payment Date d <br /> Payment Type ✓ Invoice# Check# Received By: <br /> r <br /> c Cie IC/ CJ <br />