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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> 07,J/OPERATOR/ / / <br /> r CHECK If BILLING ADDRESS <br /> ACILITYN ' �� .L Int } ��y '-(9 art_ I� C c(�-� S <br /> SITE ADDRESS112 ; <br /> N (� V^ ( c SS,l.o y <br /> Street Number Direction Street Name Zi Catle <br /> HOME or MAKING ADDRES§Af Differ t froite Address) <br /> 2 L/0 m Slreel Number �� Street Name <br /> CITY J N� ATNFDUZIP <br /> PHONE#1 ExT. APN# r/0 LAND USE APPLICATION# <br /> y <br /> Rol) - / Cl cJ Lr/ <br /> PHONE#2 EXT. BOS DISTRICT _ LOCATIOty CODE <br /> ( ) VA�t//1 1 11 VST <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST <br /> r 1 LI ( S T CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE EXT. <br /> (�� a� �L.lnlc: W Yip e'I S o <br /> HOME Or MAILING ADDRESS FAX# <br /> Yo3 ( c) 'r s ( ) <br /> CITY STATES 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 /> also certify that I have prepared this appli ti n and th���lAe work to be pert rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S nd FEDE Kaws. <br /> APPLICANT'S SIGNATURRE j+ DATE: <br /> PROPERTY/BUSINESS OWNER Ips OPERATOR/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 information <br /> t0 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. 13A V'"n..a <br /> TYPE OF SERVICE REQUESTED: —� Cl Cp� 1-J � 0 � - .v k-1V <br /> A <br /> COMMENTS: v <br /> L/G �/^ �8"'/ /o C"T 12 2017 <br /> �7� 'f� SAN JOAQUIN CO <br /> ENVIRONMENTq�TY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: F:I D � EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: O /- PIE: <br /> Fee Amount: 105-�') Amount Paid /sa,(� D Payment Date 161) 1211-7 <br /> Payment Type nvoice# Check# Receiveh By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />