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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1�006S�X07(� c5t5 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ,/fir r1J- r PDa D ("]_tr 41 T(7J C�'��_ <br /> Street Number plrectlon 'V� �' Str¢¢[Name J 4' � 'JCI ZIP Code <br /> HOME Or MAILING ADDRESS If Different from Site Address) <br /> 4d . Street Number Street Name <br /> CITY I _ O� STATE ZIP <br /> PHONE#1 �( f�f ExT. APN# LAND USE APPLICATION# <br /> 0-10 4$5-6c)3/ <br /> PHONE#2 ENT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR C0V6a r <br /> CNECK if BILLING ADDRESS <br /> T <br /> BUSINESS NAME PHONE# Eu. <br /> , �l p1k v - 9 <br /> HOME or MAILING ADDRESS FAX# <br /> 5�i-f �1✓e ( ) <br /> CITY / vr0 STAT L rf 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 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. I ^ / <br /> APPLICANT'S SIGNATURES:: 4;,I UQ Ja k '4(-c(/E� DATE: LJnQR�2 ` 14 <br /> PROPERTY I BUSINESS OWNER t / OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 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 provided t0 me Or <br /> my representative. (� <br /> TYPE OF SERVICE REQUESTED: f-- ) �51 J 11"01,1/D J� <br /> MEN I <br /> COMMENTS: RECEIVED <br /> �l�/�✓ 0 o✓ aff r t_Is c 6 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: / /� i /r. �i EMPLOYEE M DATE: -2 / 7 <br /> ASSIGNED TO: �� / EMPLOYEE#: DATE: /-'—?9/ j7 <br /> Date Service Completed (if already completed): SERVICE CODE / PIE: C)Z <br /> Fee Amount: Amount Paid Payment Date .el' <br /> Payment Type - Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br />