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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 12-SERVICE REQUEST# <br /> rG�o o�p� 1S (DID g(D � <br /> OWNER/OPERATOR <br /> U fv 1k C I ~ CHECK if BILLING ADDRESS� <br /> FACILITY NAME �tL ` C 1 <br /> SITE ADDRESS 122 <br /> Street Number I Direction Street Name---- CityZi Code <br /> HOME Or MAILING ADDRESS (If Different rom Site <br /> Address) <br /> 0 �� C vu Street Number7 Street Name <br /> CITY STATE Zip <br /> Ln <br /> e f <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /1 fVfVYk( t�( CHECK if BILLING ADDRESS <br /> BUSINESS NAME /`�'t2�SS T��, l/l� O PSL t P q1 # �1 G' C� EXT. <br /> HOME or MAILING ADDRES i �� 1 FAX I# I <br /> Co r-01 vio M W ( ) <br /> CITY CQ _ rC v 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 /> I also certify that I have prepared this application thr to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE an EDERAL w <br /> APPLICANT'S SIGNATURE: U DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirle <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� CI to me Or <br /> my representative. �1,`A.�,t <br /> TYPE OF SERVICE REQUESTED: C �� /`/ <br /> COMMENTS: 714 r <br /> 3p <br /> SAN'1oq 2019 <br /> FN�I QU�N <br /> H�C7N�FPM �N�Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: jD(p I P/E: ��2 <br /> Fee Amount: 1rp Amount P /52, Payment Date 5 <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />