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SAN JOAQUL, —OUNTY ENVIRONMENTAL HEALTH _ _PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ADDI°LL9v'D '9'accfi;to�- <br /> OWNER/OPERATORii L�� (401 ZO n: <br /> V (//1 CHECK If BILLING ADDRESS <br /> FACILITY NAME Los C w ,ti u t- '? <br /> SITE ADDRESS S Cr �vNh `�1 1�f�1 - ��- <br /> Street Number Direction l� —�SGtreet Name `fit Clt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7 7 <br /> ?SStreet Number T { Street`Nam_e�/ <br /> CITY � � 1 STATE P ^ ZIP <br /> P 1 EXT. APN# LAND USE APPLICATION# (/ I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` `^ lJ <br /> Ma LA1 't <br /> 1 rG�l 1 CHECK If BILLING ADDRES <br /> BUSINESS NAMELas <br /> �, C ,� a PHHONNEE <br /> Las ,# Ems' <br /> co✓ t' I-d, "O-� lilJ � l <br /> HOME Or MAILING ADDRESS U50 <br /> A ' n_ FAX# <br /> CITY STATE n ZIP (a <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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: �— — 2 01 C7 <br /> PROPERTY/BuSINESS OWNER OCIiRATOR/MANAGER ❑ (-:�THE4UTHORIZED AGENT❑ <br /> IfAPPLICANT Is nol the BILLL%'(i 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUN-TY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /` �M/ <br /> COMMENTS: <br /> RECElVEp <br /> AUG 3 0 2019 <br /> Li, <br /> NVIRp JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 <br /> ASSIGNED TO: EMPLOYEE M DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: t(� f Amount Paid ' Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />