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SERVICE REQUEST <br />Type of Business or Property <br />F IILIITY ID # <br />SERVICE REQUEST # ,! <br />OWNER I OPERATOR <br />BUSINESS NAME <br />BILLING PARTY 0 <br />FACILITY NAME <br />SITE ADDRESS <br />856,Street Number <br />Dtrelf>�1P <br />-0 4A ` Stmt Name <br />MAILING ADDRESS <br />7— <br />Type <br />Sulo t <br />Mailing Address (If Different from Site Address) <br />CITY e /22 T <br />STATE 011� <br />CITY f ` V V� <br />l <br />STATE ZIP <br />PHONE#1 Err. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #ZT• <br />7( <br />BOS;DISTRICT <br />LOCATION CODE <br />j CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOOR <br />BILLING PARTY 0 <br />r <br />COMMENTS: <br />BUSINESS NAME <br />PHONE#T• <br />NAYMEN i <br />MAILING ADDRESS <br />7— <br />FAX # <br />91'� <br />Gni <br />CITY e /22 T <br />STATE 011� <br />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 a d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. J <br />- -� APPLICANT SIGNATURE: DATE: �y /'/'e'-/` <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />ltAPm c wr is not tho B,urrc Pura Proof of authorization to sign f; rayuirvd <br />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 environmental/Site 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: <br />r <br />COMMENTS: <br />NAYMEN i <br />RECEIVED <br />APP, 16 2001 <br />SAN JOAQUiN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION" <br />INSPECTORS SIGNATURE: <br />CONTRACTORS <br />SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE #: <br />Uj <br />DATE: <br />ASSIGNEDTO: <br />EMPLOYEE#: <br />? <br />DATE: <br />Date Service Com eted (if already completed): <br />SERVICE CODE: C- <br />P f E: -3 <br />Fee Amount: 17 `?� <br />Amount Paid <br />a O CL-' <br />Payment Date % <br />Payment Type <br />Invoice #' <br />Check 9 q q n <br />Received By: , <br />