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SAN JOAQUIi JUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G'N s� s�,'on {FAA 0� a Q5 � <br /> OWNER/OPERATOR <br /> L v c- ou nk r\ 4 Or G C Of <br /> CHECK If BILLING ADDRESS <br /> Ll <br /> FACILITY NAME �e r C ou Y'1\� S �Or C'J C � <br /> SITE ADDRESS C Lil Qhy � o ' IL; Q a N �( 3 /6 .6 <br /> 3 Street Number Direction I Street Name \ City Zip Code <br /> Hror MAILING ADDRESS (if Different from Site Address) <br /> , 0 aV Q a` 0 Street Number Street Name <br /> CITY STATE -Z3 <br /> 61 G <br /> 1� I a4,aw�a C-1" <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (405) G8-7- 1060 Zy 33 L.) 03-1 <br /> PHONE#2 EXT BOS DISTRICT' LOCATE DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING AoDRESStr <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> 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 <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �� / D'0 I <br /> PROPERTY/BUSINESS OWNER❑ RATOR/MANAGER OTHER AUTHORIZED AGENT❑ Chv(ru►wv\tr}til /t/IA hclj e 2 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. G.'-i1 CwV\tV S)"'J 0'C C <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> AUG 222017 <br /> ENVIRONr,P�'ENTAL HELTH <br /> ACCEPTED BY: lD et�a m CC o� EMPLOYEE#: C� DATE: { Q , <br /> 1,2 <br /> ASSIGNED TO: EU CLY1 <br /> � '`&-o EMPLOYEE M DATE: O <br /> Date Service Completed (if already completed): SERVICE CODE: /�Cr P I E: <br /> Fee Amount: 415b Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />