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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 /> 1 � CHECK If BILLING ADDRESS <br /> L• <br /> FACILITY NAME <br /> " �1 <br /> SITE ADDRESS L4'? I� P, 5-' m A /V 4 cc,,A <br /> Street Number Direction Street Name city 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 /> 7 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 2P � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( t <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 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 appli tion and that the work to be erf6rmed will be done in accordance with all SAN JOAQUIN <br /> en <br /> COUNTY Ordinance Codes, Standards, ST E„ d FEDERAL Ia <br /> APPLICANT'S SIGNATURE: / DATE: r� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT MI A41A G 6? <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required l'iI <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 /> to 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. �q <br /> TYPE OF SERVICE REQUESTED: ' els n �ac,, PAYMENT <br /> COMMENTS: <br /> r E8 13 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVOENTAL <br /> H D <br /> EPARTMENT <br /> ACCEPTED BY: rn/1 ..� EMPLOYEE#: DATE: <br /> ASSIGNED TO: S. �1 Y I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C3 Z-.7' P I E:r <br /> Fee Amount: Amount Paid 5� ___ Payment Date -2 1 3 I <br /> Payment Type /L�` Invoice# Check# D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> -7y <br />