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SRN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /4- o67,D :)) <br /> OWNER I OPERATOR _ f / <br /> 1 r m /'t L,I, el �],�s t6 of &J CHECK It BILLING GpARESS� <br /> FACILITY NAME 1 u�L�JV[O tip]�7JCJC 1 L <br /> Qr <br /> SITE ADDRESS Q `r �� —S C�` -l S:jZ <br /> _ <br /> StreetNumber I Direction Srrc_e+Name GIPe ^rc�e <br /> tfOV` AILING DDRESS (if Different from Site Address) <br /> SI[i JPO " V �E` U+i_ <br /> reet Number 1 lslfreetName( W+[" <br /> CITY �CL STATE Cof zip 15-39,C) <br /> 395- ,u <br /> c.) <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> a�, Cn� � • �l� [ cs <br /> i P".'i'NE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> ReQuEsroR B)t <br /> �y �IRA' <br /> IS <br /> CHECK If BILLINu ADDRES <br /> �� <br /> 1 1Ext. <br /> PHTn" ONE# <br /> BUSINESS NAME <br /> (Pm <br /> ON <br /> HOME or MAILING ADDRESSI q 0 O � _ � 1`� � � FAx# <br /> 1t�iLILI 1 c til 030 35 .. <br /> CITY V--C/�.�b ri STATE lf1 f ZIP OI 3�o <br /> BILLING ACKNOWLEDGEMENT: 1,, the undersigned property or business owner, opera'tor 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Sfanda ds, STATE and FEDERAL laws. p <br /> APPLICANT'S SIGNATURE- DATE: 0 <br /> PROPERTY/BUSINESS OWNER O� _RATOR I MANAGER OTHER AUTHORIZED AGENT P OMCs M� � <br /> IfAPPLfCANT IS Of the B! LING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION 70 RELEAS RMATION: 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> SEP'2 2 2016 <br /> COUNTY <br /> ACCEPTED BY. EMPLOYEE#: EMVIRCI IRMNT <br /> ASsiGNED TO: n �r EMPLOYEE#: ��� DATE: _ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: `--�)C� Amount Paid ���, — Payment Date Q 22 } (P <br /> Payment Typo COWt Invoice# Check# 0 0j'5-7S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />