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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 /> C� oyu �\( ���j-e� CHECK if BILLING ADDRESS <br /> FACILITY NAME n 1 C LA ��e�'J C/ r ` � <br /> SITE ADDRESS —2+(C) S A�C II <br /> C <br /> Street Number Direction Street Name\/ `� /h Ci Zi Clod[—eV <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2�Z U N Yinm V1 49, <br /> Street Number Street Name <br /> CITY �f✓� t STATE C/As- ZIP C�sz—o <br /> PHONEJ1 EXT* APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t '�, 1 -erJ CHECK if BILLING ADDRESS <br /> BUSINESS NAME w `V CV P}IpNE�/ �I '1� ED <br /> HOME or MAILING ADDRESS r� w FAX# 11� 1 ! �J <br /> .2 L l/ IJ 2 rV1 CA Irl Vx c ) <br /> CITY1 STATE I�/\ 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 /> 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:' DATE: �I_D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER 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, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same timej1�ISpf �t�1le Or <br /> my representative. PAY" , <br /> TYPE OF SERVICE REQUESTED: KO v-e h t r/ <br /> COMMENTS: App p 1 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: - ' r lU Q Pvi V EMPLOYEE#: DATE: <br /> ASSIGNED TO: "C—) <br /> ' k1 ( EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: V(jo I P/E: `2 <br /> Fee Amount: Z _ Amount Paid l Payment Date / <br /> Payment Type ` Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />