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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �� FAobol �(q� �2c��915 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME - /� <br /> SIT AD Rl y TIC? '� <br /> Street Numb¢r Direction 1y beet Name CI ' "` Zip Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PNE#1 APN# LAND USE APPLICATION# <br /> (5o a3- o ExT o (� <br /> PHONE#2T BOS DISTRICT LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK CHECK If BILLING ADORES <br /> BUSINESS NAME ^ GN PHONE# ExT. <br /> J - KO <br /> — <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 specifc 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 wort o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE an RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 711LLII ! <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I 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, 1, 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: RECEIVED <br /> CV t��� � o �' �✓i � .fUL 13 2018 <br /> SAN JOAQUIN COUNTY <br /> -.-ENVIRONMENTAI <br /> ACCEPTED BY: EMPLOYEE M nriiLIMIE <br /> ASSIGNED TO: EMPLOYEE#: DATE: - 17J -r� <br /> Date Service Completed (if already completed): SERVICE CODE: 0 PIE: /&0 <br /> Fee Amount: _ Amount Paid 4 _ Payment Date -7 // :3 <br /> Payment Type CC't,S Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />