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SAN JOA�QRLIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE E$# <br /> a�q,tr �� yam SR <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> CAISL)� <br /> FACILITY NAME <br /> SITEc, <br /> If <br /> ESS T v" GM [� D l 9�Z r <br /> 7/ t5lr'e'e"t`Number Direction 3[reet Name Cit Zi Cotle <br /> HOME or MAILING rant from Site Address) <br /> Stree[Number y Street Name <br /> CITY STATE ZIPn�� O <br /> � Si GC K �/✓T (- `7� <br /> PHONE#1 EXT. AP # / LAND USE APPLICATION# <br /> (26 7�� 7y`� 7 X6 <br /> PHONE#2 ��r l /GT. BOS DISTRICT LOCATION CODE <br /> ry) <br /> S-7 5/ <br /> CONTRACTOR/ SERVICE REQUESTOR n <br /> REQUESTOR CHECK if BILLING ADDRESS LJ <br /> LEL /-W 0 <br /> PHONE# Ems' <br /> BUSINESS NAMES eAA� L/N� 20 5- <br /> K <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY � lfwf STATE G1-A ZIP —tS ZIy <br /> 31LLING ACKNOWLEDGEMENT: 1, 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 /> .,_tivity will be billed to me or my business as identified on this form. <br /> I also certify the, 1 have prepared this applicati nd that ork to b performed will be done in accords ice with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STA a EDER Al <br /> APPLICANT'S SIGNATURE: DATE: 2 I <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT i5 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 ocatec at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the same time It Is Oro, led to me or <br /> my representative. <br /> TYPE OF SERVICE RE4JESTED: CI I ec)L _PAYMENT <br /> COW ENTS: ��_ <br /> Wim OCT`21 2015 <br /> SAN JOAQUIN COUNTY <br /> t ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: n �T( EMPLOYEE#: DATE:I Q 1. <br /> 31_ IS- <br /> ASSIGNED TO; a-cxs�11 r/ EMPLOYEE#: DATE:tb - � <br /> r�Z <br /> Date Service Completed (if already completed): SERVICE CODE: 2 P IE: )(� <br /> Fee Amount: o ' Amount Paid _ Payment Date _-- <br /> Payment Type !- _` Invoice# Check# Received By: - Z <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />