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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REOUEST# <br /> �-zrf' So% IA-ku �65-tj f�Db IN Ib -��Ob �� 3 <br /> . <br /> OWNER/OPERATOR <br /> C c,UfrU k�leso IQ /Ivy CHECK if BILLING ADDRESS <br /> FAGLITY NAME f (! <br /> SITE ADDRESS L t-C1 <br /> 3,,25' y 9s <br /> Street Number Direction Street Name Cif Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (4149 q1L 9,;2-7�D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Q�vr � � <br /> PH�f # Get' 6� ExT. <br /> HOME or MAILING ADORE FAX# <br /> ire Ae (q)(,,) 6q6 9663 <br /> [CITY <br /> STATE �y Q 3� <br /> rA v A hn��� zip�1t '3 <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 or <br /> 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: I � DATE: <br /> s <br /> PROPERTY 1 BUSINESS OWNER❑ ithfLLING <br /> RATOR 1 MANAGER [3 OTHER AUTHORIZED AGENT <br /> If APPLICANT Is noPARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA§E 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 environmentallsite 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: VST AYM2N <br /> COMMENTS: R°ECENED <br /> 0r.C 1 2 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: a EMPLOYEE#: ❑ATE; ZZ <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (ifalready completed): SERVICE CODE: Sc ift PIE' 0U <br /> Fee Amount: j,� Amount Paid S(� -- Payment DS ate l a, a� <br /> !r <br /> Payment Type C �L Invoice# Check# -3 a Received By; <br /> EHD 48-02-025 R <br /> ld <br /> SR FORM(Golden od <br /> 07!17/08 ( ) <br />