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SAN JOAQUICOUNTY ENVIRONMENTAL HEALTH DE RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#/ <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY111AME , Lb) <br /> OD {070 <br /> k SITE ADDRESS J0f HAW <br /> c57-7� ��T✓rl X11 f 1.L—fl ti�3 <br />.' _ Street Number Direction Steoet Name citv Zip Cade <br /> I HOME 0r MAILING ADDRESS (if Different from Site Address) ! �� O 1 1� 7}��& <br /> _ IStree!Number !�[.• ✓ Street Name <br /> CITY „ A C ZIP <br /> ' PIiONF 41 f�� � EXT. API# LAND USE APPLICATION# <br /> (p?) 64G - 3rg <br /> i <br /> PH ON.-#2 EXT. BOS DISTRICT LOCATION C04E <br /> c 1 — C� 1--- <br /> CONTRACTOR/ SERVICE R QUESTOR <br /> r �REQUESTOR CHECK if BILLING ADDRESS <br /> ! <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> r CITY STATE ZIP <br /> BILLING ACKNOWLEDGEN4ENT: 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: � r DATE: <br /> PROPERTY BUSINESS OWNER OPERATO MANAGER OTHERAUTHORIZED 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 /> r t0 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. _ <br /> TYPE OF SERVICE REQUESTED: Cb Y7 f;�-+C ' TQ cn �PAYMENT <br /> COMMENTS: I 1iEv r ti E <br /> .!U N 4 9 2016 <br /> SAV JOAQUIN COUNTY <br /> s ENViROMENTAL. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> kASSIGNED TO: �1 I f� EmPLOYEE#: DATE: <br /> kDate Service Completes! (if already completed): SERVICE CODE: PI E`' <br /> Fee Amount Amount Paid C) Payment Date fig,r <br /> Payment TypeInvoice# Received By: <br /> ' EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />