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• SERVICE REQUEST 0 <br />Type of Business or Property <br />BUSINESS NAME � C%2C% i�j^„ L L <br />PH0q / • <br />13-3 <br />FACILITY ID # <br />o� 6 <br />FAX <br />SERVICE REQUEST # <br />oc 2 f4�-- - <br />OWNER/ OPERATOR <br />BILLING PARTY ❑ <br />FACILITY NAME <br />RECEIVED' <br />y, <br />SITE ADDRESS /%�(//`�� <br />V '� "StrNt Numbr <br />L <br />:S, k-® Harm <br />SAN JOAOUIN COUNTY <br />TT <br />Suits 0 <br />Mailing Address (If Different from Site Address) <br />CITY <br />INSPECTOR'S SIGNATURE: <br />STATE Zip <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 2 <br />aT• <br />EJrPLQYEE# �J? <br />BOS DISTRICT <br />_ <br />LOCATION CODE. <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR BILLING PARTY ❑ <br />BUSINESS NAME � C%2C% i�j^„ L L <br />PH0q / • <br />13-3 <br />MAILING ADDRESS � D � ,� l <br />(f <br />FAX <br />CITY �{ STATE ZIP O - <br />BILLING ACKNOWLEDGEMENT: 1,undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />Puauc HEALTH SERVICES EWRONMENTAL F�A4TH OrrSIoN hourly changes associated with Ibis project or activity will be billed to me or my business as identified on this form. <br />FEDERAL that I hav r red �� n afld jai tha �torfc ro _be performed wil be done in aaordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />APPuGANT SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER Cl OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />N APP[.cwr is not the Bum Purry proof of wemazallon to sign is mqui w 'i t r e <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 environmentalisite assessment information to the SAN JoAQUN COUNTY Pusuc HEALTH SEFmcEs ENv1RoNmENTAL 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: U-57— <br />57— <br />COMMENTS: <br />COMMENTS: <br />PAYMENT <br />RECEIVED' <br />JAN 2 3 2002 <br />SAN JOAOUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH 01VISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />Euncy-a)T: <br />SATE: Z <br />ASSIGNED TO: <br />EJrPLQYEE# �J? <br />DATE: <br />Date Service Completed (if already completed): <br />U <br />SERVICECODE: <br />-P / E <br />Fee Amount:. 7 <br />Amount Paid ° <br />Payment Date A . $n <br />Payment Type <br />Invoice # <br />Check # � a � 3(0 <br />Received <br />