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SAN JOAQU*COUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICLREQUEST# <br /> OWNER I OPERATOR <br /> I V t, n/V� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ce� �C� Cr Cry <br /> SITE ADDRESS 5 7 p CSS�>7 � Tcl� <br /> 2 J <br /> Street Number Dlrectlon Street Name CI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) ' Z2- 12 16 I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (2% )1-171 SJ 6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME { I I O S L C r e P?6# Z2 __ z 6 EXT. <br /> HOME or MAILING ADDRESS '7 t 7 �y (� I r FAX# <br /> CITY 0 '/_I t STATE / A 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 Fe AL laws. <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 Titte <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. PMMFNT <br /> TYPE OF SERVICE REQUESTED: V V Al V a"&v 1 1 RECEIVED <br /> COMMENTS: •, <br /> 1)ew cm AUG 0 7 2017 <br /> 84kN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEWTMENT, <br /> ACCEPTED BY: r rl J EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: �o Amount Paid Payment Date r <br /> Payment Type C cZ Invoice# Check# Received By:'�) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />