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SERVICE REQUEST Type of Business or Property /�Zd —44 �A 'l BILLING PAJIZTr �� i FACILITY ID x SERVICE REQUEST SH, a- rq ox/ Exr. 3 90 /d Date Service Completed (rf already completed): SERVICE CODE: P I E;_a.?O OWNER OPERATOR I FAX ; �i� BILLING PARTY Q EQutLox-1 - YTf_ R f E LLC Payment Type FACILITY NAME Check # 36 & 6) q Received B . SITE ADDRESS Q�� v StreK Number Ovec7on I �1�%aR RDr Strxat Name Type Suiui Mailing Address (If Different from Site Address) Z ,l CITY STATE11 Z1P ce 46_/ PHONE "'1 �T• + APN� LAND USE APPUCAT'AN (511 (,,/x}-8390 �°3 I PHONE 92 aT• HOS DISTRICT _ � LOCATION CODE _ re)?JTRACTOR I SERVICE REQUESTOR RcOUESTOR /�Zd —44 �A 'l BILLING PAJIZTr �� i SNA ASSIGNED TO: AI BUSINESS NAME PHONE it is Exr. 3 90 /d Date Service Completed (rf already completed): SERVICE CODE: P I E;_a.?O MAILING ADDRESS c� 130 & I FAX ; �i� cTY L S TATE C� I LP -77 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, adasowleCge that all site and/or project spec^: PUeUC HEALTH SERVICES EWRONMENTAL HEALTH OMSION hourly, charges associated with this project or activity will be bided to me or my business as iderrtu5ed an this fort'. I also certify that I have prepared this application and that the work to be perfomled will be done in accordance with ad SAN JOAQUIN CouNTY Ordinance Codes, Standards, STATE anc FEDERAL laws. / � APPLICANT SIGNATURE: / G DATE / ,+0✓ / / PRCPERTY I BUSINESS OWNER C OPERATOR I MANAGER C OTHER AUTHOR= AGENT crPER/'tI / ,EX PERI TO /; If APPI— wr rs not UX g t 1110 P iwr proof of audrar=don to sign is rsvuinW Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address. hereby authorize the release c any and all results, geotechnical data and/or environmentaVsite assessment inforrnatlon to the SAN JOAQUIN COUNTY PU13UC HEALTH SERvcz-s EwncNuE(TAL HEALTH ONIZON as Socr as it is available and at the same time it is provided to me or my representative. P��F, j�l i TYPE OF SERVICE REQUESTED: COMMENTS: EIVED ❑r U C T 3 1 2000 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION INSPECTOR'S iIGNATURE: APPROVED BY: . dCf /�Zd —44 �A 'l ESIPL^ F / i �s�j I DATE' 1, ASSIGNED TO: AI �� EMPLOYEE':' J DATE: `0v– -30 – D"jJ Date Service Completed (rf already completed): SERVICE CODE: P I E;_a.?O Fee Amount Amount Paid ��/ c U Payment Date V �� Payment Type I Invoice # Check # 36 & 6) q Received B .