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SAN JOA—iIN COUNTY ENVIRONMENTAL HEAL. )EPARTMENT <br /> SERVICE REQUEST <br /> Type of B iness t'r Property FACILITY ID# SERVICE REQUEST# <br /> 71�'cr <br /> OWNER/O'ERAT, R <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ( t � �1 t( ��,`t x I G R O L GU <br /> p is f� ,�) <br /> IV4� 9�IW. .? Il/1 l '�}' '�r t` <br /> SITE ADDRESS 3 d a d (v Cl 1+� `j 1 F:> <br /> C�LIL(�vel �Q�p <br /> StreetNumber Direction Street Name Ci Zip Code <br /> HOME Or MAILING C)/ADDRESS (If Different fromSiteAddress) <br /> ' 1 `✓ Street Number Street Name <br /> CITY STATE ZIP <br /> S�ci, 0 r'1 C-A2�1 ' 1 scgc)) <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR SQL rr�1� CHECK if BILLING ADDRESS <br /> Q =�� � t�(�r✓2 CIS <br /> BUSINESS NAME PHONE# ExT, <br /> - 1 q <br /> HOME or MAILING ADDRESS FAX# <br /> 2 - 714 ( ) <br /> CITY -5—t <br /> oCv- ( 0Sv STATE ZIP q'Cil O <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 identi=that <br /> orm. <br /> also certify that I have prepared tis applicatic work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stand YATE EDERAL laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY I BUSINESS OWN R ER I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT t the BILLIN PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO REL/EASE 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 provided t0 me or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 00 `t (kn, i i� <br /> COMMENTS: �t/t I /�I� J U IV L 6 2017 <br /> �I if SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> y� HEALTH DEPARTMENT,, <br /> ACCEPTED BY: I V EMPLOYEE#: DATE: a <br /> ASSIGNED TO: 1 S�j EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J 1 E: Mu I <br /> Fee Amount: 00 Amount Paid --I Payment Date ^) <br /> Payment Type ^ �a°0 Invoice# Check# — — Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />