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SERVICE REQUEST 0 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�j � 2v►c- F �rAcTi d � <br />� . � ���"-�.' <br />f2� <br />OWNER / OPERATOR <br />BILLING PARTY ❑ <br />FACILITY NAME <br />C l 2L) 74, 7 KiT d ✓u <br />SITEADDRESS <br />13-7T Strut Number <br />DLV <br />Direction <br />Street Name <br />Type <br />Suite 0 <br />Mailing Address (If Different from Site Address) <br />CITY —7'11-A( <br />STATECAzip <br />953 7A <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />(2414--) 7v4c - Z 33 /. <br />PHONE #2 EXT. <br />BOS:DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR /� � <br />L.l�22Y CA/2 PFU•—"—� C' -A2 ( ) I BILLING PARTYO, <br />BUSINESS NAME PHONE# UT.LCS2 <br />�vrc€S W51�U-! 73a <br />MAILING ADDRESS n FAX # <br />,Z 7 t'A2 kv # yyY-1 ?mss <br />CITY ,! 12 STATE GA ZIP 9 <br />37Z <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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. , <br />APPLICANT SIGNATURE: L,/ - - DATE: Z-16-01 <br />PROPERTY BUSINESS OWNER ❑ OPERATOR/ MANAGER❑ OTHERAUTHORI ,D AGENT <br />II APKr—wr is not the ©rticrc Parry prop of authoruadon to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentallsile 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 />COMMENTS: <br />INSPECTORS SIGNATURE: <br />APPROVED BY:. " <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: 2 <br />Payment Type (�V 1invoice #- <br />PAYMEN*I' <br />RECEIVED <br />FEB 16 2001 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />CONTRACTORS SIGNATURE: <br />EMPLOYEE #: DATE: O <br />EMPLOYEE #: DATE: <br />SERVICE CODE: ( PIE: <br />Amount Paid' I Payment Date <br />Check # G�S� 1I Received By: <br />