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SERVICE REQUEST <br /> Type of Business or Property ^� FACILITY ID# RVICE REQ EST# <br /> F :EZZ-0117L11�" <br /> OWNER OPERATOR - <br /> - CHECK IT BILLING ADDRESS <br /> FACILITY NAME ��/^, , L <br /> SITE ADDRESS (///���(�r�/r AJ /�yllT %�,�/N��r�L'/�T \/1��1--,`\' C, Z <br /> S0 Street Number Direction r ` vt y Street Nart B `� ` CIcv 21/Coda <br /> HOME Or MAILING ADDRESS <br /> -(if <br /> �Different from Site Address) I Or <br /> Street Numberdyz-`-1Ylt/`l- treSet ame <br /> CITY STA ZIP ` <br /> PHONE#f ExT APN# LAND USE APPLICATION# J <br /> (2i ) U6X �lFl�1� I� ILIP 1P I <br /> PrIfQ �) I ,� ,l /�I L1 ExT BOB DISTRICT LOCATION CODE <br /> 1 C/4�/( Y VX r�1t i <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ;2�58- CHECK if BILLING ADDRE <br /> BUSINESS NAMEr ._C05 PHONE# C, ETT' <br /> Ar.� N� U e6 OI ��d kq <br /> HOME Or MAILING ADDRESS )V 1 ^ f�{_ ��L O <br /> CITY '1`( [- 11J5 U STATE l 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, STATE and F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2��M6 <br /> PROPERTY/BUSINESS OWNER❑ —OPERATOR/MANAGER 11 /c OTHER AUTHORIZED AGENT /, 1a <br /> If APPLICANT is not the BILLING PAR zr proof of authorization to sign is required Titre <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 enviromnental/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 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SA FB 2 9 2016 <br /> Ej,gQW,V <br /> HEgLTH br:q ti MINT <br /> ACCEPTED By EMPLOYEE#: DATE: <br /> ASSIGNED TO: -+� EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount PaiJ7, � Payment Date add <br /> Payment Type I� Invoice# Check# /��� 2. j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod1 <br />