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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 I OPERATOR n t J <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME � <br /> L-�_ <br /> SITE ADDRESS /�)/} 1 I(/+ �-!/ <br /> `,aDire i t/` ""ltr8e N`YT/ 4 �:� 71C'" <br /> Zip Code <br /> HOME or MAILING ADDRESS (I Different rom Site Address) <br /> ` Street Number Street Name <br /> C.CITY STATE CA— ZIP C^— <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> l�7L-t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / 7 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# JJX <br /> HOME or MAILING ADDRESS FAX# <br /> CITY i' STATEZIP �/� <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 <br /> or 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 perforned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandards, STAT and FEDERAL laws, f � d� <br /> APPLICANT'S SIGNATURE: i----� DAPI : C G� 2-L` <br /> t'RO!'ER"I'Y/BUSINESS OWNER❑ I'ER:ITOR i MANAGER O"rHER AUrHORI'LED AGENT❑ <br /> 1JAPPLIC'ANT is n(N the B/LLING PARTY,prooJoj fithorization to sigh is regirired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When, applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all iesults, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENWRONMENTAI.HEALTi-i DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED' _ _ o <br /> COMMENTS: <br /> AN <br /> 16 2020 <br /> S FN OAQUIN C <br /> HEALTH,D,,rA ULIY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: / Z <br /> Fee Amount: <� 1 (;-L— Amount Paid Payment Date <br /> Payment Type Invoice# Cheek#. 8 �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />