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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDN SERVICE REQUEST <br /> �s ST a� A 000 3 �I o <br /> OWNERAI0 ERATOR <br /> C! C�S 11n CHECK if BILLING ADDRESS I+ <br /> FActLm NAME J\ kc I, "i r�l S -4' F,= <br /> SREIIADDRE arar^ -H A �p r � 4 �oi„ ,STDc-k`i'<J <br /> 1 r✓ SMet MSW IStr"t MaimI C e <br /> HOME Or MAILING ADDRESS Of Different from Site Address) <br /> 3hnt Number Street <br /> CITY P-A G A A--.o <br /> <`- STATE zip <br /> PHONE Nt Exr. APN A i7�.� /^� E LAND USE APPLICATION# <br /> PHONE I2 EXT. BOS DISTRICT LOCATION CODE <br /> l ' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECIUESTOR /t Gi , ,�I Jv o A"-k'r) T CHECK If BILLING ADDRESS <br /> J f 1 (�/ Ir 1� j.. <br /> BUSINESS NAME kA a 3 s sz <br /> It HOME O MAILING ADDR SS FAX I <br /> CITY S T,1 Tu!`� STATE OVI zip S p <br /> 5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> at acknowledge that all Site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form, <br /> 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 FEDL laws. " <br /> APPUCANrS SIGNATURE:, �� DATE: 0 •v <br /> PROPERTY/BUSINESS OWNER IJ OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT ❑ � <br /> If APPLfCANT is not the B/LLING 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmentaUsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. }} <br /> TYPE Of SERVICE REQUESTED: Ai <br /> V �4 <br /> COWENTS: 13fz,-q/a p �'I e�- far PW-e— 4�x- UAC-' <br /> s A <br /> res -�...� /Y. VC) <br /> - 2 18 <br /> ON UNC <br /> ACCEPTED BY: /,t !1 /1 a V,1 Q EMPLOYEE M C(" DATE: 7�21_ T TMENT <br /> ASSIGNED TO: /v�l1L w f0` EMPLOYEE M. l DATE: ✓-3'24-17 <br /> Date Service Compl ffalready completed): SERVICE CODE: <br /> Fee Amount: Ll Amount Pal �� �(� Payment Date 3 <br /> Payment Typet Involce# Ch ck# 5 1 Recelved By: <br /> In I- :A `QED <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 J <br /> ENVIRONMENTAL <br /> HEATH DEPARTMENT <br />