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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NMV,,,/-P707- fA OOO 2.v 2OoS1(D12. <br /> OWNER/OPERATOR &�b L fil� <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS J ` /1/1A-r + L4 K'16 StOGK:F}1v q —M <br /> Street Number Direction ` teeNime city Zlo Code <br /> HOME 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 /> 01- 6 002 <br /> / CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` 4 J CHECK If BILLING ADDRESS <br /> BUSINESS NAME Jl PHONE# EXT. <br /> phi <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 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, TATE and FEDERAL laws. / (� <br /> APPLICANT'S SIGNATI. 411 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVED <br /> C^^'VE <br /> N U 9 2020 t1w1% <br /> SAN JOAQUIN COUNTY PEW 41, rA[y <br /> ENVIRONMENTAL SFR <br /> ACCEPTED BY: C64Jf :,A 5 l.J EMPLOYEE T DATE: <br /> ASSIGNED TO: �v [�L�l J. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: t � <br /> Fee Amount: 2 Q� Amount Paid Payment Date 7 alp <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />