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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 61 o o 60 —7-73( � <br /> OWNER I OPERATOR r ( / CHECKifBILLINGADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2C`,J� / l�Ps7L �JQ��'�/��C /g U(. /:" / �1• 95 36 <br /> Street Number Direction / Street Name cE ZI Code <br /> HQME Or MAILING ADDRESS (If Different from Site Address) Vq/'"WC/ S)` <br /> Street Number Street Name <br /> CITY 112 _!(` SATE ZIP27 9 f <br /> PHONE#1 1 ExT• APN# LACND USE APPLICATION# „ ( <br /> tzc�) 362 -9 3Zg <br /> PHONE#2 EXT. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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�to <br /> I I also certify that I have prepared this application and that thew be performed will be done in accordance with all SAN JOAQUI14 <br /> COUNTY Ordinance Codes,Standards,STATE and L la 7 <br /> APPLICANT'S SIGNATURE: DATE: G/j 2 T/7 <br /> PROPERTY BUSINESS OWNER❑ OPERATOR/MANAGER PC OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> F 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 me or <br /> my representative. [� r <br /> TYPE OF SERVICE REQUESTED: [�� <br /> 1 �}� ` 'i-t �� f ItiI <br /> COMMENTS: <br /> PM 17 2017 <br /> SAA'JOAQurN <br /> 11 H D pAR Mt nrr <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: _ Q EMPLOYEE#: DATE: a� <br /> Date Service Completed (if already completed): SERVICE CODE: }�l PIE: (Q <br /> Fee Amount: 3 Amount Paid 1 vU Payment Date .27/ <br /> n <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />