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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1-7 �6y�a- <br /> OWNER/OPERATOR <br /> CHECK Ift31LLING A0UFE5S� <br /> FACILITY NAME <br /> 1 <br /> SITE ADDRESS <br /> 4141.11 //--�I TSL SST <br /> `TlCtrEer Number Direction Stree[Name Ci Li Cede <br /> NOIJF or MAILING ADDRESS (If Different from Site Address) <br /> _. <br /> Scree[Nun bei Street Name _ <br /> ry <br /> STATE ZIP <br /> PHONE)t EXT. APN# '0 `-90,!� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR P��P��ie'e� <br /> CHECK If BILLING ADpRE$S'V! <br /> BUSINESS NAME PHONE# EXT' <br /> e IS QQ I� yz- Z <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY fz S A Z <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 /> I also certify that I have prepared this application andat-tk ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard- rA� and FEDE L taws. <br /> APPLICAN 'S SIGNATURE: DATE: I <br /> PROPERTY/BJSINESS OWNER Y"'' 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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. �1 <br /> TYPE OF SERVICE REQUESTED: (m'I fir <br /> COMMENTS: � �^� ^�-'� <br /> o Wi l'C! MAR 11 2016 <br /> SAN OAROMENTOUNTY <br /> q' HEALTH DEPARTMENT <br /> ACC dPTED BY: lJl EMPLOYEE M DATE: <br /> ASSIGNED TO: �I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE. �� PIE: <br /> Fee AAmount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: -- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />