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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 ' HECK If BILL NG ADDRESS <br /> ��ur�tn 1—e�Y'�o�+�lc�o Dc. 1 �� 1 c�r� �� <br /> FACILITY NAME n YJ d n I I ne,-t s �/`�e- 1 co� <br /> SITE ADDRESS I�/��a IF- `11.. C► O Me„/1 Street Number Direction Street Name ` Ci V ` Fq':D--22--4 <br /> Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �p-2- 1 �� U-)!^ I <br /> Street Number Street Name <br /> CITY / �I— 1.^ STATE ^� ZIP 6 � <br /> PHONE#1 l� 2�v l EXT. APN# LAND USE APPLICATION# <br /> (201 `�Y 7-7 9`5 <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST_ _ <br /> De 1`� -Tb,f f e ��,�j��� CNECK If BILLING ADDRESS <br /> BUSINESS NAME Ad, <br /> d n 1 hC 1��'J c lllm-e�I C CA n �3 O `PH ��r Exr. <br /> HOME or MAILING/ADDRESS FAX# ll� <br /> ZO `, m levyl ( > <br /> CITY �/ -1 STATE ( p ZIP (�S <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 /> 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,Z�� <br /> ++�� <br /> APPLICANT'S SIGNATURX <br /> E: DATE: V i 1C'1 <br /> PROPERTY/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 It Is provided to me Or <br /> my representative. WMENT <br /> TYPE OF SERVICE REQUESTED: �r C oYl �.l t <br /> COMMENTS: REGEIVED <br /> JAN s 1 2019 <br /> _0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: VJQ EMPLOYEE#: DATE: \�- ?S II— 1C1 <br /> ASSIGNED TO: � I ` OL <br /> EMPLOYEE#: DATE: 1 —?)1—lcl <br /> Date Service Com leted (if already co pleted): SERVICE CODE: Y <br /> I /1 L P/E:I I <br /> Fee Amount: l N Amount Paid (52 pv Payment Date <br /> t <br /> l i 3t <br /> PaymentType�tS0. Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />