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9 <br />• SERVICE REQUEST • <br />Type of Business or Property <br />V S .r J/K l go rZ_ <br />FACILITY ID # <br />BUSINESS NAME <br />(�(%�, � TO ►-( E � C. t � E. � 'fZr -Y-t; , mac. c <br />SERVICE REQUEST # <br />PHONE# <br />EXT. <br />COO Co <br />(9f 6 <br />OWNER OPERATOR <br />MAILING ADDRESS <br />BILLING PARTY ❑ <br />EL A,L.,Nt E <br />RECEIVE® <br />FACILITY NAME <br />qrb <br />3:�-3- /t'4 -L <br />04 1Q—AKAA11— XXOti( <br />STATE C A, <br />ZIP y S`6 q <br />SITEADDRESS <br />S <br />L <br />T. <br />Street Number <br />Olreceon <br />HEALTH DEPARTMENT <br />SUW Han* <br />TYDe <br />Sulo! <br />Mailing Address (If Different from Site Address) <br />APPROVED BY:. <br />IJ <br />A <br />EMPLOYEE M% DATE: <br />C <br />ASSIGNED TO: <br />CrTY <br />S -t-o c-fG re, '-4C <br />EMPLOYEE #: ��/� <br />STATE ZiP <br />A C(- S- z o 6 <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />(Z01) `P Sri - ( ? 0 6 <br />PHONE #2 En. <br />Fee Amount: <br />T-0—s)ISTRICT LOCATION CODE'. <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTORX <br />V S .r J/K l go rZ_ <br />BiLLWG PARTY <br />BUSINESS NAME <br />(�(%�, � TO ►-( E � C. t � E. � 'fZr -Y-t; , mac. c <br />COMMENTS: <br />PHONE# <br />EXT. <br />(9f 6 <br />2 - <br />MAILING ADDRESS <br />FAX # <br />RECEIVE® <br />qrb <br />3:�-3- /t'4 -L <br />CITY S R A w1 O <br />STATE C A, <br />ZIP y S`6 q <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 activitywill be billed to me or my business as identified on thls form. <br />I also certify that I have prepared this application a that the work to be perfo ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance, Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE: 3 A Y— <br />PROPERTYI13USINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT _ Ca O wT 2 Ja tJF O IZ <br />If Aver cwr is not the Brtterc Pnnry Proof of authorization to sign Is requirod 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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 />V S .r J/K l go rZ_ <br />VIA O V I F( C A—T Y o 4 <br />COMMENTS: <br />PAYMENT <br />RECEIVE® <br />MAR 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />INSPECTOR'S SIGNATURE. <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. <br />IJ <br />o <br />EMPLOYEE M% DATE: <br />C <br />ASSIGNED TO: <br />C <br />EMPLOYEE #: ��/� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CGDE: <br />PIE: 2309 <br />Fee Amount: <br />Amount Paid -1 — <br />Payment Date 9 <br />Payment Type <br />Invoice # <br />Check # s� <br />Received By: <br />