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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ::IjFACILITY ID# SERVICE REQUEST# <br /> T� 0 .. _ _ d I n'T:, <br /> OWNER/O , ATOR L�P��oZ� CHECK If BILLING A"RrSSFd11 <br /> — <br /> FACILII(ITpTTY//NAME vS/7 f` 17 C' <br /> SITE E55 r/ G I TIJ Pi J� V�J 7— �'✓�+ <br /> St_,A :um.er Obectlon Street Name CI ., otl. <br /> HoM-or MAIUNG-A.)DDhLES ( Differer.rfrom Site Ad'-'ass) � fjjgGff �/J <br /> Street Numt Str.et Name <br /> CITY `L// STATEZIP Q / <br /> PHONE#1 <br /> // Ezr. APN# LAND USE APPLICATION# <br /> (3-30) Gq�lay00 <br /> PHONE#2 E%T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR If SERVICE REQUESTOR <br /> 1Ap� <br /> REQUESTOR / ��O'�.. ` — CHECK if BILLING ADDRESS LJ <br /> ,/11 ILII <br /> EXT. <br /> BUSINESS NAME PHONE# 3�, <br /> �- vz 3 <br /> Ho L,:,31NG AD7 RC JO�.C� � Fax# — <br /> S ( ) IP <br /> ( CITY STATE /� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the ,;ndersigneo property or business owner, operator or authorized ag'an, of sarus, <br /> acknowledge that all site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> ac:'vity will be filled tome or my business as i intified on this for, <br /> I a'sc cc-lfy ' at I have prepared th' Auatlon nat the work ;o be performed will be done IT a-cor`♦ance with all SAN JOAQU.L <br /> COON Y L..d:1,ance Codes, Stand ds, STAT E RAL lawn. <br /> APPLICA.N'i'S SIGNATURE: _ DATE: 2 <br /> PROPERTY/BUS:NESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORRED AGENT ❑ <br /> IfAPPLICANT Is n-: file BILLING PA,7Y p,oof of authorization to sign is required Tirir - <br /> AUTHORIZAiION TO RELEASE INFORMATION: When applicet;'e, I, the owner or operator of the property located at t'o: above <br /> site address, hereby authorize the release o'any and all esults, geotechnical date. and/or environmental/site assessment informatio:l <br /> to the SAN JOAO `i COUNTY ENW,JNMENTAL HEALTH DEPARTMENT as soon -s it is available and at the same time it is provided t:: me or <br /> my representative. - --' <br /> _ �-t� P 1ta h Cyl2G� <br /> TYPE OF SEHVICL REQUESTED: <br /> COMM.,n. .. <br /> 0 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED SY: EMPLOYEE#: DATE: <br /> A^SIGNED TO: ' ' `10 n!'A EMPLOYEE#: DAIE: <br /> Data Snr•icetompieted (i tlready completed)' SERVICECODE PIF: <br /> Fee Amount: C _—TAmount Paid Payment Date <br /> Payment Type Invoice# Check# ( ,-�., Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />