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SAN JOAQUIN %,tJUNTY ENVIRONMENTAL HEALTH DE, _ ATMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPEIkATCIRCHECK If BILLING ADDRESS <br /> FACILITY NAME ,j V,) G-T- fy4W <br /> SITE ADDRESS /\ ' �/'I'C S ° " S T-Q41- 6-Al U <br /> •7 Street Number Direction I Street Name city Zip Code <br /> OME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) ciZ' U <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMETfKj' M�i I\„,J� PH NE - — E.T. <br /> HOME or MAILING ADDRESS FAX# <br /> U ( ) <br /> CITY T Cg <br /> _mz 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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:: / DATE: <br /> �} <br /> PROPERTY I BUSINESS OWNER LTJ OPERATOR/MANAG 0 OTHER AUTHORIZED AGENT ❑ '—T <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tire <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. <br /> TYPE OF SERVICE REQUESTED: Rn Cki,S u Q PAYMENT <br /> COMMENTS: RECEIVED <br /> GVLG��2 0 W n erJLEC 2 2 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: L /LI EMPLOYEE#: DATE: I ^� .�� (-7 <br /> ASSIGNED TO: Rv L "ll EMPLOYEE#:41 1DATE: _ / <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 1 O <br /> Fee Amount: C Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />