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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 13 <br /> /An1� ��-e <br /> FACILITY NAME <br /> Srtoc..�`Co w� `Uw'tc IT I on <br /> SITE ADDRESS Wa`D-er S {— STzx,K�� ��jZDZ <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2 .J 3 Street Number Street Name <br /> CITY ��(� STATE ZIP Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# V <br /> ( ) -'Itcl 33b - 335'1 \ -3 2021 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /G C CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME i PHONE# - E ' <br /> r t�1 �✓� <br /> HOME or MAILING ADDRESS FAX# <br /> G r bh Y}ve ( ) <br /> CITY G _SCI 1 m CA-_ ^7 CJ 2 (-) y 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F L 1 . <br /> APPLICANT'S SIGNATURE: p DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT ❑ <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� mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS prOVJ(�t(?d Or <br /> my representative. lr4 All 1p ". <br /> TYPE OF SERVICE REQUESTED: Tbovl Oan (,�bJ - S COMMENTS: fCtOr Ct..b- t`C1�C� � V`�r eG� 1r � � We Lr TL . I <br /> MF�'T <br /> ACCEPTED BY: � EMPLOYEE#: DATE: <br /> ASSIGNED TO: M . EMPLOYEE#: DATE: u <br /> Date Service Completed (if already completed): SERVICE CODE: j 2 3 PIE: kvo I <br /> Fee Amount:4P L4S�0 -- Amount Pai Payment Date <br /> Payment Type Invoice# Check# 31/6 Received By: <br /> EHD 48-02-025 t SR FORM(Golden Rod) <br /> 07/17/08 <br />