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I o 11.1 t k 'IC, I at <br />tel - <br />SERVICE REQUEST <br />EH0061SR revised 09/04/98 <br />Type of Business or Property , FACILITY ID # SERVICE REAWESTA — <br />0 I I 0 6 <br />OWNER/ OPERATOR BILLING PARTy . <br />FACILITY NAME t <br />—tio t I (MG( <br />SITE ADDRESS ,--) 57 --refitke',/t/ <br />Street Number <br />govo <br />Direction <br />s44-1,44c Street Name Type Suite # <br />Mailing Address (If Different from Site Address) <br />S(1°V14,tf-- <br />STATE ZIP <br />PHONE #1 Exr. <br />PA, (4 /‘-(C( <br />APN# LAND USE APPLICATION # <br />-5c,t) /44 tvi Liar, Capt.q- VC:4 <br />PHONE #2 EXT. <br />(760 9 4-(if --(7 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />1 <br />REQUESTOR <br />ilt [ 1r0-g(TO <br />BILUNG PARTY 47 <br />BUSINESS NAME @At_ <br />, <br />PHONE # <br />( 5-op <br />En. <br />6.9k (i9 <br />MAILING ADDRESa FAX # <br />( ,Q0 n:C44— <br />STATECrrY ZIP q-2_,t,c, <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br />me or my business as identified on t rm. <br />I also certify that I have prepared/this plication and that t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standards, STATE a <br />APPLICANT SIGNATURE: <br /> la <br />DATE: <br />LI OTI-IER AUTHORIZED AGENT 6Q-1 <br />If APPucANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: R) <br /> 0 \P LeX <br />OTHER COMMENTS III SPECIAL CONDMON(S) OF APPROVAL I II <br />PAYM E N') <br />RerPrvcr, <br />OCT 6 1998 <br />,,,,,, JUI;OUIN (..;!..1- r4 T'T PUBLIC HEALI-I1 SERVICES <br />ENVIRONMENTAL F-jEALii-i OIVIStOr, <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br />APPROVED Br'.4. Aj\,Q, os _ t_ts_e6.14( EMPLOYEE #: f 6) t DATE: O • ve, <br />ASSIGNED TO: 12u6„, <br />--(\--Q--1\r\ <br />EMPLOYEE St: (72 (-1 C(l DATE: <br />Date Service Completed (if already completed): SERVICE CODE: -.5 D 3 P/ E: <br />Amount Paid 31 i,d,o0 Payment Date <br />{0((2- <br /> 61 <br />t <br /> 0-) Fee Amount: ) ,_0-r-) <br />Payment Type \ <br />' / Invoice # Check # I I CV,—(-) Received Ey: 4.2 <br />PROPERTY / BUSINESS OVVNE