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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4j,' 'V16-7& N e c �- <br /> OWNER/OPERATOR ,,,. � <br /> CR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE A _ � <br /> Street Number Direction Street Name city ZiD Code <br /> HOME or MAILING ADDR SS (If Different from Site Address) <br /> G Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT• APN# LAND USE APPLICATION# <br /> 9,3 �aic� oRbf:noo '� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME/ ]� �L�f/l�/C _� PH ,# �/J� EXT. <br /> HOME Or MAILING ADDRIESS,7 n•-'7 �J--� >_ - �/ ' FAX# <br /> CITYr l P / 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 that e to be performed will be done in accords ce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FED I I <br /> APPLICANT'S SIGNATURE: ��3D <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATO ANA R ❑ OTHER AUTHORIZED AGENT* nL � <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7'ir[e <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS� to me or <br /> my representative. n r•/. , <br /> TYPE OF SERVICE REQUESTED: Z IVE <br /> COMMENTS: <br /> 3 0 2018 <br /> N1V oRpNM COUNrY <br /> EALTIy DEPS MEN. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 31 <br /> -l� <br /> ASSIGNED TO: EMPLOYEE#: DATE: Ll_E)c —' <br /> Date Service Completed (if already completed): SERVICE CODE: CJZ� PIE: 4; <br /> Fee Amount: Lk--0- ,e <br /> — Amount Paid 5 Payment Date 41 30 <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />