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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busi1 �ness or Property 1 FACILITY ID# �kooSERVICIEREQUESiT l <br /> ou <br /> OWNER/OPERATOR A i//_n CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 0162 <br /> uCl t <br /> Street Number Diroctlon Street Name CI ZiCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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 <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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STand FEDERAL s r7 <br /> APPLICANT'S SIGNATURE: / DATE: <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 <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. p�T <br /> TYPE OF SERVICE REQUESTED: �- c�4 lvi � PAY E 1 <br /> COMMENTS: VE D <br /> F EB 1 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH RTMENT <br /> ACCEPTED BY: EMPLOYEE#: 2 DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z t, 3 DATE: L (-' / <br /> Date Service Co pl ed (if already completed): SERVICE CODE: 6 PIE: v Z <br /> Fee Amount: Z Amount Paid 1 2 — Payment Date <br /> Payment Type a 1� Invoice# Check# Received By: <br /> EHD 25 �y -7 SR FORM(Golden Rod) <br /> REVISEDSED 11 11/17/2003 <br />