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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />&,f-,* L) R� <br />FACILITY ID # <br />�-7 1 I l 1314 <br />PHONE # EXT. <br />SERVICE REQUEST # <br />S � 6 % g <br />_-� <br />f� <br />OWNER I OPERATOR gop'7-�"j <br />CHECK If BILLING ADDRESS <br />FACILITY NAME 9z 1t e t/� <br />�j W\ n <br />JUL <br />SITE ADDRESS <br />ENV/F?O/V COU <br />HEgCT <br />fy� L <br />�� I <br />c , q <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />_Z3147 <br />HOME or MAILING ADDRESS (If iffier nt from Site Address) <br />EMPLOYEE #: <br />DATE: <br />% C'Street Number <br />Street Name <br />A,qTE <br />CITY f ( Ci/SbL4 l;j �' O <br />`# t <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION <br />(7o -r 3 3Z 6G Z Ll <br />Payment Type /'.. , <br />Invoice # <br />Check # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ) CHECK if BILLING ADDRESS O <br />BUSINESS NAME` ,' b / �A IE� <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY I STATE CIA 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 applicationd t at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an FE WS. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Ti rle <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 />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. AA, <br />TYPE OF SERVICE REQUESTED:aA <br />CIV <br />COMMENTS: <br />Co <br />s� 8 2019 <br />JUL <br />ENV/F?O/V COU <br />HEgCT <br />y DEPARTTA �T Y <br />ACCEPTED BY: <br />( S <br />EMPLOYEE #: <br />DATE: 7 / <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: G <br />PIE: I C) <br />Fee Amoun Clvi <br />Amount Paid <br />Payment Date <br />Payment Type /'.. , <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />W4 <br />