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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />l -1 0 U v i2 S 1 (0 R ►= <br />FACILITY ID # <br />� -e u') <br />PHONE# EXT. <br />k-1-7 7 3 3 <br />SERVICE REQUEST # <br />i "7 9? OD <br />OWNER / OPERATOR I<U Q U V I L <br />J r H J O 5 I5 PH !"/j I H I F 7 I t- <br />F-- - I t-I✓� I CHECK If BILLING ADDRESS <br />FACILITY NAME I'\'I I: �- J 10 <br />1 1 l� 0 1� S <br />,^ C� <br />SITE ADDRESS (0 2 Z 1 <br />Svl i+e �0' Street Number <br />Direction <br />i - W r 1= S I <br />L- P N j_ <br />Street Name <br />cS i OG K ! L� ��( <br />city <br />C <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />PHONE #1 EXT. <br />( ) <br />APN # <br />yL/C 503, <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DIST <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR [ P 040T--10-1- <br />4 0-1- <br />I� U � � V i � � � � O$ �-- (- � 1�• I � I � I / I +4 I L CHECK If BILLING ADDRESS <br />BUSINESS NAME M l^� 1 i /_"') i t 01Z S <br />I 1^ v t!� <br />PHONE# EXT. <br />k-1-7 7 3 3 <br />l f <br />HOME Or MAILING ADDRESS 6 `� 2 ( (� + U I , a �S T (^�� Ij G <br />FAX # <br />CITY S I G 1<-1-0 M STATE C i ZIP C}52-10 <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: Py% ' DATE: �d <br />PR <br />RTY / BUSINESS OWNER ® 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 />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time itip <br />I ed to me or <br />my representative. ' VED <br />TYPE OF SERVICE REQUESTED: PICLI-N. <br />% UC - PAYMENT <br />COMMENTS: RECEIVED `' <br />2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />FEB 2 8 2098 HEA! TH DEPARTMENT, <br />SAN JOAQUIN COUNTY <br />FNVIRnNMFN <br />ACCEPTED BY: �QC� /Z` EMPLOYE& ALTH DEPARTMENT DATE: '-9 23 <br />ASSIGNED TO:1� l EMPLOYEE #: DATE: - -2 _ <br />Date Service Completed (if already completed): SERVICE CODE: > PIE: C 1 <br />Fee Amount: 1� f4o L \' Amount Paid (� S Payment Date • <br />I <br />Payment Type(,, j(�— Invoice # Check # '� 3,q q Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />