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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS .7 L4 <br /> r ~1 a ,V(.J , <br /> Street Number (rection Street Name Ci Z1 Code <br /> HOME or MAILING ADDRESS (If Different.from Site Mcl)ress) I �� <br /> umber Street Name <br /> CITY ^ /�Y�C ISC� STA ZIP �06 <br /> PHONE#1 t�' ► r En. APN# LAND USE APPLICATION# <br /> (� 5 -� 6. 052- 140- 50 <br /> PHONE#2 FxT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRA TOR/ SERVICE REQUESTOR <br /> REQUESTOR j <br /> c CHECK If BILLING ADDRESS <br /> BUSINESS DAME j PH / EXT• <br /> as --?�2 <br /> HOME or MAILING ADDRESS / 4 :.X# <br /> CITY STATE ZIP 1't(0 <br /> BILLING ACKNOWLEDGEMEN . 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 <br /> or 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_§AN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDER ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OIYNER❑ O BATOR/MAN R ❑ OTHER AUTHORIZED ACEN\ <br /> 1ffIPPLICANT is not the BILLING PARTy.proof of authorization to sign is required TTN <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: SSS <br /> COMMENTS: CC-V'`� <br /> l OCT 18 ° <br /> 2019 <br /> SqN JOAQUI <br /> HE'gNVIRONMEN UNC <br /> ACCEPTED BY: EMPLOYEE#: DATE: /6 /> T <br /> ASSIGNED TO: w EMPLOYEE#: DATE:/o >! <br /> Date Service Completed (if already completed): SERVICE CODE: ?�, I E:4-4 <br /> CU <br /> Fee Amount: ( L Amount Pai /6-; , Payment Date <br /> Payment Type sem_ Invoice# Check# C}S Receiv d El <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />