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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQVEST—,-7 <br /> Type of Business or Property FACII,ITY ID# SERVICE REQUEST#OWNER 10 RATOR CHECK If SILLINo ADpREs$ <br /> ff <br /> �. crVO <br /> FACILITY NAME <br /> SITE ADDRESS ito <br /> Mi, Zip Cod$— <br /> HOME Or MAILING ADDRESS (If Different from Site Address) l <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Err• w d S_DISTRICT LOCATtONCODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQuESTOR <br /> fd [vim'r CHECK if BILLING ADDRES$13 <br /> BUSINESS NAME V� PHOIJE# EXT, <br /> HOME Or MAILING#ADDRESS FAx# <br /> CITY .STATE � ZIP <br /> 13ILLING ACKNO .EDGEME : I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that-all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> } I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE• DATE: d3 <br /> PROPERTY/BUSINESS OWOPERATOR I MANAGER © OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BILLING PAurr,proof of authorization to sign is required Title <br /> AUTHORIZATION TQ RELEA,$A AgOR , 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 SA14 JOAQUIN'COUNTY ENVIRONWNTAL`HEALTH DEp�iTMENT as soon as it isavailable and of the safne titne it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: " pW%tiGt S � (,onSwl a^ RECEIVED <br /> COMMENTS: JUN-2 4 2016 <br /> t SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Da EMPLOYEE#: - DATE: 12 Ll <br /> f ASSIGNED TO: Lgd1i L+ haws EMPLOYEE#: DATE: f,� <br /> Date Service Completed (if already completed): SERVICE CODE: S C D U P i E' 1(por <br /> Fee Amount, ly v Amount Paid {3 () Payment Date <br /> E=d <br /> Payment Type �.� Invoice# Gheck# a Receive By: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />