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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH GtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> //;/z 1� CHECK if BILLING ADDRESS <br /> FACILITY NAME /Gt <br /> SITE ADDREyS.S�i"�/3���Fi� ��if�� _ <br /> SS" � Street Number Direction Street Name CI ,ZipCode <br /> HOME or gMAILING ADDRESS (If Different from Site Address) lj P/�'1�c C Z!)tl—� y <br /> �f Street Number Street Name <br /> CITY 1 STATE ZIP <br /> PHONE#1 EXT. APN LAND USE APPLICATION# <br /> PHONE#2 EXT. BIDS DIST IC; LOCATION c .DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �-- <br /> ��� CHECK if BILLING ADDRESS• <br /> BUSINESS NAME CC PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ri� STATE ZIP �� u <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. <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 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: ' /C S i'G © PAYMENT <br /> COMMENTS: RECEIVED <br /> 1���4R Z 7 2018 <br /> �G7 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: `\ ,1� EMPLOYEE#: DATE: / <br /> ASSIGNED TO: Y�/1 EMPLOYEE M DATE: <br /> Date Service Complete if already Completed): SERVICE CODE: Q J PI!E: 0 <br /> Fee Amount: Amount Paid Payment Date 3 <br /> Inv <br /> Payment Type \ ;ice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />