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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 <br /> FACILITY NAME Y ✓\I , {' n l p <br /> SITE ADORES�M�\ OW •_/T^ry���Ot✓rt J� l -/ sZO) <br /> Z E' Stre¢t Number Direction Street Rates CI ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) de le ,1�r <br /> Stree[Number Stree[Name <br /> CITY � ' GATE ZIP <br /> PHONE#f EXT. APN# LAND USE APPLICATION# 1�+ <br /> PHONE#2 EXT. BOB DISTRICT LOCATIO CODE <br /> (G)ML �i ©O % C� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ W I Y <br /> bEmb <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME .j, ( I PHQNE# / EXT. <br /> #c `(SAI ��(O�c <br /> HOME Or MAILING ADDRESS 95(,- 1 ei le Y (AX# ) <br /> CITY l/ STATE cl. 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 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: <br /> DATE: <br /> PROPERTY/BUSINESS 3L <br /> OWNE r{� <br /> RIOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment informtion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it is provided o. Or <br /> my representative. .. <br /> TYPE OF SERVICE REQUESTED: �'c J� L 1 2018 <br /> COMMENTS: SAN JOAQUIN COUNTY <br /> ', 1 I EEENVVIIRONMENTAL <br /> Cj�c,/1C� L%? L vJrle> TUB 7LlG��i�1.Lc'IH c _i PlrRTMENT, <br /> ACCEPTED BY: � '! EMPLOYEE#: DATE: <br /> ASSIGNED TO: t)1 EMPLOYEE#: DATE: <br /> Date Service Completed (if al ady completed): SERVICE CODE: C • , PIE' /6,6 1 <br /> Fee Amount: `Jj` 6J Amount Paid , ' 'l Payment Date !� _ I�-_ <br /> Payment Type ` - Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />