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SAN .JOAQUIN COU14TY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Txxpe of Byysine s or property FACILITY ID# SERVICE REQUEST# <br /> I eC7 A-�ti, S2c��� 5s <br /> OWNER/oPERATO <br /> I l,� �A1. it vlA � CHECK if BILLING ADDRESS <br /> FACIUTTY`JJNAAMYYE�` WI'r tI` f,/`• }� <br /> SITE ADD <br /> 2 S ()O Street Number Olrection eet Name Ve— C 21 Code <br /> HOM Of MAILING A ESS (If Dlff7gfrptnJ Site Address) <br /> t Street Number Street Name <br /> CITY` /�eSTATE ZIP Ir <br /> PHONE#t En APN# c LAND USE APPLICATION# / <br /> PHONE#2 ExT. BOS DISTRICT LOCA11 //T]]10 CODE <br /> ( ) 005 —\ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /.OVA_ CHECK If BILLING ADORE55 <br /> BUSINESS NAME Ow Y` /O 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 /> also certify that I have prepared this application and thatle work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE fl FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER It1- 90iTOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not th ILLING PARTY,Proof Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE FORMATION: 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 Sam a It is provided to me or <br /> my representative. //� 11 n 6�°+" Y <br /> TYPE OF SERVICE REQUESTED: � t(rr'fL �JWA.t �7-tr� V�Q,Vt�\J-r r(� `��O (�+) <br /> COMMENTS: //�71/y0/7 91 Z6 '/N/I-�M✓ RevieI�S�A� tJCL 26 2017 <br /> (AAIV- COP44 L%t L7,- HEALTSAN ORONMEN7-AL y <br /> OepARThfENT <br /> ACCEPTED BY: r'tar,..(._f�,� EMPLOYEE#: DATE: I)-;LG-i7 <br /> ASSIGNED TO: P� EMPLOYEE#: DATE: I I-X-17 <br /> Date Service Completed (if already completed): ff SERVICE CODE: �� PIE: 260,J <br /> Fee Amount: Z)4r� Amount Paid 3DT• O U Payment Date 12r21o/ 17 <br /> Payment Type t/ Invoice# Check# Received By: t6 <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />