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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/OPERATOR <br /> 12. <br /> � I ? CHECK K BILLING ADDRESS <br /> FACILITY NAME <br /> 0 <br /> SITE ADDRESS }StreetNumber o� a i►� S s t�� t1 L' �i Po %L6 <br /> HO �MAIUNG ADDRESS (M Dwerent from Sib Address) <br /> v —1-S d X, 309S t Number <br /> CITY � I\ C 4 TS 36-6 <br /> PRONE#1 Err. APN# LAND USE APPLICATION# <br /> l�v�r► `I�3 1 )59 <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"T. <br /> L L � �' I�.,v►� vci a 3 11,59 <br /> HOME or MAILING ADDRESS FAX# <br /> Po 'T3c x 3 o Li ( ► <br /> CITY \ s C zP '753 66 <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 he performed will be done in accordance with all SAN JoAQuIN <br /> CouNTY Ordinance Codes,Standards,STATE and FEDERAL laws. l <br /> APPLICANT'S SIGNATURRE:: DATE: G -- /6 6— ��oAo_ <br /> PROPERTY/BUSINESS OWNERD j6PERATOR/MANAGER ❑ R AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 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 results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ant{ me time it is <br /> provided to me or my representative. f?i���Ai°tdll//�1V,- <br /> TYPE OF SERVICE REQUESTED: coo, r1l, <br /> COMMENTS: 19 2020 <br /> SAN <br /> E ,JOAQUIN DOUNry <br /> o VI' > k t H�ITH pE ART ENT <br /> ACCEPTED BY: L4n LA 6 l r S EMPLOYEE#: / DATE: , i Z U <br /> ASSIGNED TO: C-� (/1 EMPLOYEE#: �J lJ�• DATE: <br /> Date Service Completed (it already completed): SERVICE CODE:J PIE: <br /> Fee Amount; G)A u Amount Paid I sa , _ Payment Date <br /> Payment Type Invoice# Check# 3Sg Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> NP,o csl)�Z�U <br />