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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fly OOD5�7$ -7 <br /> OWNER/OPERATOR <br /> jCHECK If BILLING ADDRESS <br /> FACILITY NAME L <br /> j <br /> SITE ADDRESS '(�^ �/� <br /> Street Number Direction R'�I n ° �•,r Jt ,Name V J-' '^ U CI ZiJ Cotle <br /> HOME Or MAILING ADDR S (If Different from Site Address)81 C It1�/• t' C <br /> Street Number Street Name <br /> CITY iG V'\' ST TE ZIP <br /> PHONE#1 EZT. APN# LAND USE APPLICATION# <br /> ( a�) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR m <br /> (� CHECK If BILLING ADDRESS <br /> BUSINESS NAME O RHONF# ExT' <br /> Y cls )E -303 <br /> HOME or MAILING ADDRESS �13 FAX#( ) <br /> CITYI STATE ZIP <br /> 01 1 <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: a rrrtttJJTTT((`//��^ DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR ANAGER 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 /> 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. <br /> TYPE OF SERVICE REQUESTED: Fvu� PNMENTp <br /> COMMENTS: RECEIVED <br /> houY plan NOV 21 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: /I 17 G EMPLOYEE#: DATE: 1111 <br /> ASSIGNED TO: e ✓l. l l EMPLOYEE#: DATE: I 11 II,. <br /> Date Service Completed (if already completed): SERVICE CODE: (('C 152 3 PIE: <br /> Fee Amount: ' �'7g 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 />