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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/,.OPERATOR <br /> L CHECK if BILLING ADDRESS <br /> FACILITY NAME /tel c <br /> VL J <br /> SITE ADDRESS ✓� �; LOA � C� �2 � <br /> I i . I Street Number Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> )'G � ` 1- Street Number Street Name <br /> CITY STATE ZIP <br /> LUQ, A " A `51/, <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /A�Y tC)E <br /> g CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> z-) <br /> HOME or MAILING ADDRESS FAX# <br /> PC) 1--21v'tc 13 116 D 1 ( <br /> 'q,77-0-3C—) <br /> CITY P , AtG STATE ZIP 6t <br /> S C� <br /> BILLING ACKNOWLEDGEMENT: <br /> 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 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, ST TE and FRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: i WUZJV 1y <br /> PROPERTY/BUSINESS OWNER� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof Of aUthO//Zati~1011 t0 S19n IS leQUl/e[l 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: �I ^V l �� , RPAYMENTECEIVED COMMENTS: R ECF I VE D <br /> DEC 0 6 2016 <br /> SAN JOAQUIN COUNT) <br /> ENVIROMENTAL <br /> HEALTH DEPA TMIEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: f -, <br /> ASSIGNED TO: - 1 ` `- a _ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z `j P/E: q--26 <br /> Fee Amount: Amount Paid -,7 Payment Date / <br /> Payment Type Invoice# Check# Received By:,--, _. <br /> r� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />