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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> <Z �179 <br /> OWN /OPERATOR <br /> - CHECK If BILLING ADDRESS <br /> FACILITY NA E o <br /> SITE ADDRESS/0,�?, JC''�C�S <br /> Street Number Direction / treet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) J <br /> Street Number -�/ Street Name <br /> CITY STATE ZIP <br /> v - 2 <br /> PHONE#; EXT. APN# r, �p / LAND USE APPLICATI N# <br /> 3 S'F 2 JL <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /' /V r ,, / I <br /> 1 U CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME C/ VVV x F� V PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:T%i% % r��� DATE: — 13, <br /> I ROPERTY/ USINESS OWNER OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAPPLICANT is of 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Gl <br /> v LIAR 13 2020 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7� <br /> ASSIGNED TO: VU, S'�,,,,^ EMPLOYEE#: DATE: C <br /> Date Service Completed (if already completed): SERVICE CODE: -213 /E: Z <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />