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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cie,S 1't�e s�' °'V\ FP--om': 1 1 GI 11 JW- <br /> OtIJKIE ;O'ERAFOR ( n <br /> CHECK if BILLING ADDRESS <br /> r4CILITY NAME p a <br /> SITE ADDRESS ?4 T 6� <br /> a 1, <br /> StreNumber Direction Street Name _ 1 I CI -_-_ Zi .CJodee_ <br /> l;OME or <br /> (M�AILINgG ADDr.ESS (if`-Di�lerrr.t from 'Site Addr ss) <br /> I- IOOi_ ��G.\v\� {J� Street Number Sireet Name _- <br /> CITY STATE ZIP �y <br /> I�C1t.v arts � c � <br /> PHONE#11 EXT. APN# � LAND USE APPLICATION# <br /> 90C. <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> 4 �- <br /> CONTRACTOR SERVICE REQUESTOQ _ <br /> REQUFSTOR <br /> I k�V � � � CHECK If BILLING ADDRESS <br /> BUSINESS NAME �} Q {�J ;�, t PHONE# EXT. <br /> � fi" 51)G0()- 33 �� <br /> HOME or MAILING ADDRESS ' ^ FAX# <br /> CITY >�C', �-- STATE ZIP 6f4- <br /> BILLING <br /> f _BILLING Airf4NOVVLEOGEMENT: i, the undersigned property o business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALT 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 erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SiGNAT URE: K DATE: <br /> R <br /> PROPERTY I BUSINESS OWNEOPERATOR/MANAGER ❑ OTHER AU HORIZED AGENT � <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to 'gn is require 1JT?rl e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the own or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical da t and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is av ilable and at the same time it is provided to me or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: L4 5 4'pZj-pj' RECEIVED � <br /> COMMENTS: AUG 11 2016 <br /> SAN JUUOuUAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE:Com, <br /> ASSIGNED 70--�,� '- EMPLOYEET <br /> .#: DA:: <br /> Eaf^=:er;ice—Comple-Ied (if already completed): SERVICE CODE: <br /> Fee Amount: / Dt' Amount Paid L. `� Paymen Date <br /> Payment Type-J`1 i Invoice# Check# Received By:,,;,— <br /> . <br /> EHD 48-02-025 S 4 SR FORM(Golden Rod) <br /> 07/17/08 — S� <br />