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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> mod Pre( - C®Mll-)rssa /Y1FPv D�I��° SJR60 `ga-72- <br /> OWNER/OPERATOR <br /> Vx CHECK if BILLING ADDRESS f� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Citv Zi.Cnria_ <br /> HOME or MAILING A.7F.-SS (I Ifferent from Site Address <br /> i <br /> � u <br /> � U Y Street Number Street Name <br /> CITY� i � STATE � zip 7'^5--R o G <br /> PHONE#1 T \EXT. APN# LAND USE APPLICATION# <br /> (2,69) ?, - 01 9 <br /> PRONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ ,SERVICE REQUESTOR <br /> REQUESTOR ) /j Y—k 0 I�► / �tV ct (�e. CHECK.if BILLING ADDRESS El <br /> n V 1 <br /> BUSINESS NAME _ 11 �t O PHONE# EXT. <br /> HOME or MAILING ADDRESS Q _� FAX# <br /> J ` CA l '`CN'V"v�- e`er ( } <br /> CITYS' 4 0C— $TATE /'� ZIP r+��is, r <br /> BILLING ACKNOWLLEDGEMENT: I, the undersigned property or business owner, o`p—era`tor or authorizecd)agentt ofsame,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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 47i2A14 d 6 ar a d,-- DATE: 0Z <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not 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: <br /> FE COMMENTS: s s F ,77— !h <br /> F F S 2 4 2016 <br /> SAN JOAQUIN COUNTY <br /> CSM ry) ICS c� ENViROMEN'YAL <br /> HEALTH DEPAHTNIENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �()r t.�� I EMPLOYEE#: DATE: a I� <br /> Date Service Completedj((iilc�falready compleYeVdl)):: SERVICE CODE: PIE: <br /> Fee Amount: Z�U Amount Paid C9 U Payment DateG,�-2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />