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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME N l <br /> SITE ADDRESS LN 7 l vI A� 44L��+ /S ?j 3lO <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 /� EXT- APN# LAND USE APPLICATION# <br /> /v) ,y'�- s i-'�7 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( 1 ) l - 2 I �! <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �� ✓ CHECK If BILLING ADDRESS 13 <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 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 appli ion and that the work to be e rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST nd FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: c � -2 l 1 c7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �V��� G 1 <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirl e <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 /> to 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. �p <br /> TYPE OF SERVICE REQUESTED: �1�f1 CAV(-,k PAYMENT <br /> COMMENTS: <br /> = 1 3 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVWPAI IRONMENTAL <br /> DEPARTMENT_ <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: J , 1y I//I n, 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CZ P I E:I�U I <br /> Fee Amount: Amount Paid 5�_ Payment Date <br /> Payment Type Invoice# Check# D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ��to 427� s. <br />