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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 .I yl e�j <br /> V awl CHECK If BILLING ADDRESS <br /> FACILITY NAME 1p 11,1 r- I S tj.VA <br /> SITE ADDRESS 11 n IV S Y 11 ' �1 1 < � <br /> Street Number Direction Vt Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE C�A ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# �l�J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �' a CHECK If BILLING ADDRESS <br /> BUSINESS NAME t'\_ \ I� �1^!^ t ( � PH # 0014 <br /> EXT. <br /> HOME or MAILING ADDFESS ,! y V FAX# 1—Ji <br /> CITY a STATE ZIP �SZv <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, Stand 72H <br /> IaWS. <br /> ST J <br /> APPLICANT'S SIGNATURE: V DATE:PROPERTY I BUSINESS OWNER Rslot <br /> R ❑ OTHER AUTHORIZED AGENT ❑ <br /> If. PPLICANT 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time o me or <br /> my representative. VED- <br /> PrA+�Y IYmIGG1ry1,� <br /> TYPE OF SERVICE REQUESTED: '�o R <br /> EChI <br /> COMMENTS: MAI 0 3 2019 <br /> SAN JOAQUIN COUNT`( <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: h EMPLOYEE#: DATE: EfflK <br /> ASSIGNED TO: V Y EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: E�]/1 PIE: <br /> Fee Amount: 1 2 _ Amount Paid S 2-- Payment Date <br /> Payment Type Invoice# TG;Wk# 2, 3 Received By: <br /> EHD 48-02-025 ' T11ti SR FORM(Golden Rod) <br /> 07/17/08 � V <br />