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SAN JOAQUIIv COUNTY ENVIRONMENTAL HEALTH Dtt3ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID—#7 pSERVICE REEQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME / ✓��U <br /> SITE ADDRES <br /> Street Number D coon � ^�6tr�eYNSrtfa� II/x7 � �'r <br /> Ce4z <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2"l Street Number C-7 ` treet Na e <br /> CITY J STATE ;�_ ZIP <br /> PHONE#11 ExT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE C ^ ^ ExT. <br /> , C ( 3 <br /> HOME or MAILING ADDRESS FAX# <br /> STATE 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 /> 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. ) �j <br /> APPLICANT'S SIGNATURE:J oco�? �f/�y "(��) DATE: <br /> PROPERTY/BUSINESS OWNEOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT ISot 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 time It IS provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I C l C LIZ&t7 <br /> AYM <br /> IVEC <br /> COMMENTS: <br /> In lr;n cC- Vwne( VE® <br /> SEP p8 2017L/c` <br /> SAE JOAQUIN COUNTY <br /> 1-IEgLNVTN p NMENTAL <br /> ACCEPTED BY: ` ( EMPLOYEE#: DATE: C ' <br /> ASSIGNED TO: G - u EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P/E: (r,C <br /> Fee Amount: e-, ��•v 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 />