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9 tiT - <br />SERVICE REQUEST <br />Type of Business or Property ' <br />BILLING PARTY ❑ <br />FACILITY ID # <br />°" <br />LERVICE REQUEST # <br />(� a t"^C-CL <br />PHONE# <br />cq 4- 6 3 3 <br />CACI ©O 0 5-6 0 <br />CJ � <br />OWNER IQPERi1fi9R-- <br />, <br />BILLING PARTY <br />JAN % 61999 <br />RUSH <br />FACILITY NAME <br />S F <br />oA^I jOHUUIN CUU14V <br />SERVICES <br />S Lti .e <br />PUDUC HEALTH <br />ENVI8Lt41,IENTAL HFALTH DIVISION <br />SITE ADDRESS 17 KS <br />/. Q S171. <br />rutin <br />/� M L IV♦ 4+ rlS J <br />Shia r, <br />Type <br />subs <br />Mailing Address (if Different from Site Address) <br />EMPLOof—ut l <br />1 F' G 5 o� o 2 z- <br />M a vt 'e c ctc ✓C— '33 �' <br />CITY <br />EMPLOYEE # <br />STATE Zr <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />(,2oq) 2 3 <br />Amount Paid <br />Payment Date <br />PHONI�X Exr. <br />Invoice # <br />BOS DIsrRICT <br />i;.. <br />_ <br />LOCATION CODE:_ <br />Z —3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR %! r i 7— <br />CD <br />BILLING PARTY ❑ <br />cJ C2 C l< I e <br />--CD <br />BUSINESS NAME/ } � �� <br />/ e � �,,� � � �o tr- <br />COMMENTS: <br />PHONE# <br />cq 4- 6 3 3 <br />MAiLINGADDRESS <br />FAX# / 3 <br />C1r1 i _ G` <br />CITY -97-0C, a ,,- <br />STATE C Y d <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ad site and/or project specific <br />PuBuc HEALTH SERVICES EwRoNMENTAL HEALTH D W ON hourly charges associated with this project or ad %* will be tilled tD me or my business as identified on this tone. <br />1 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 IaWS. I /-—T,—v" <br />APPLICANT <br />DATE: <br />PROPERTY / BUSINESS 00VNER ❑ OPER R , y'� <br />GER ❑ OTHER AUTHORRED AGENT i / %`A T Q C <br />���" Anc�wrsnarffreS4mPvm pm&ofaudwrindoatosignisnqulyd Title <br />AUTHORIZATION T LEASE 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 amilor amironmemallsite assessment information to the Sm JOAQUIN COUNTY PuBUC HEALTH SERvIcEs EwRoNmENTAL 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: <br />P4l MF -11, <br />® <br />-e N Win,i <br />.I;F <br />JAN % 61999 <br />RUSH <br />oA^I jOHUUIN CUU14V <br />SERVICES <br />PUDUC HEALTH <br />ENVI8Lt41,IENTAL HFALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EMPLOof—ut l <br />DATE: 2 <br />ASSIGNED T0: <br />S ` <br />EMPLOYEE # <br />DATE ` Z�j <br />Date Service Completed (if already completed): <br />SERVICE CODE: . <br />-P f E:. 0 <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />--I <br />