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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �P-- po�act0 S <br /> OWNER/OPERATOR n <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSo <br /> Street Number Direction Street Name \ Ci Zip Code <br /> HOME Or MAILING AD RE If Differ nt from ite Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> nfi1) S1-1- -10 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> AIM) l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Qin , rw I <br /> `v CHECK If BILLING ADDRESS <br /> BUSINESS NAME0 Cj� us <br /> PHONE t EXT. <br /> HOME Or MAILING ADDRESS S n — V �1�� CA/\U L� ✓Y (AX' <br /> ) <br /> CITY �i l" ` STATE A ZIP C-TSZZ�— <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 FEDE AL laws. n 4 <br /> APPLICANT'S SIGNATURE: 1 DATE: '20l I (� I U <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANTxsot the BILLING PARTY,proof of authorization to sign is required Tille <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 time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: O �� -`�- PAYMENT <br /> COMMENTS: RECEIVED <br /> Nov 2 6 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: �/�U�,`� EMPLOYEE#: DATE: <br /> ASSIGNED TO: ` ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 1�C <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />