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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> $A0012LZ kx oo-&o--e�,Sq <br /> OWNER/OPERATOR <br /> r � CHECK If BILLING ADORE55O <br /> FACILITY NAME G n <br /> SITE ADDRESS ills \ EYAwa LANE 5'r()(,�'�'p� ' 5210 <br /> Street Number DlrecHon Street Name It ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EaT' APN# LAND USE APPLICATION# <br /> ( ) D -I- LI`J(l0L 2 <br /> PHONE#2 EKT• BOS DISTRICT LOCATION CODE <br /> ( ) V� �1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> R06 E T U CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> U Z cti <br /> HOME Or MAILING ADDRESS �^L FAx# <br /> , CEDE Ave to6 ( ) <br /> CIN - O STATE /` ZIP 937-2b <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 an F DERAL laws. <br /> APPLICANT'S SIGNATURE: _ �/ DATES:07/03/ 19 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT pl&i�aa- <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 thbove <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment in�fliF'r���"t <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as R Is available and at the Same time It Is provideytcmy� �NT <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: R6,y-) L. hixv rHA111 <br /> `O <br /> COMMENTS: 2019 <br /> C <br /> FNT <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: V �,/�/l In/J EMPLOYEE#: DATE: <br /> Date Service Completed`-(if already completed): SERVICE CODE S� PI E: 1 (00 I <br /> Fee Amount: s'ig Amount Pal �� Payment Date 3 <br /> Payment Type Invoice# Check# Recei cl By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />