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Ccs✓� '�U�-1� HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNT NVIRONMENTAL <br /> ,,SERVICE REQUEST <br /> Type of Business(Ir Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPEOR <br /> ' � CHECK If BILLING ADDRESS <br /> FACILITY NAME I`FL / 7 <br /> SITE ADDRESS <br /> IDD ��t'j Street Number I Direction .L LJL�t ����7G�vlCvitj� I�� <br /> Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> FREQUESTOR CHECK if BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <br /> Z< OCD <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �� a �{/, S �L� STATE /�F ZIP <br /> 'Lt l6 t I�'r' 1 tY� <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTH AUTHORIZED AGENT(6- <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 information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the SamQjltll@ It is provided to me or <br /> my representative. M <br /> TYPE of SERVICE REQUESTED: (AC"v <br /> COMMENTS: 2-.- ft APR 0 1 2015 <br /> 'SANENVIRON <br /> VIROUIN COUNTY <br /> HEALTH DEPARTMMENENT <br /> ACCEPTED BY: C rV-�k e c EMPLOYEE#: DATE: A —1 —( <br /> ASSIGNED TO: ( EMPLOYEE#: DATP9- --t <br /> Date Service Completed (i ready completed): SERVICE CODE: —2-5 P 1 E://- <br /> Fee <br /> : <br /> Fee Amount: Amount Paid a.J .c) Payment Date T l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />