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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> S1'� 0091301 <br /> OWNER / OPERATOR ,y <br /> 66,,,, ` -- ( { (( CHECK If BILLING ADDRESS <br /> , 51ADIL <br /> FACILITY NAME.- <br /> ' 7 I U k -jSITE 'J ✓� I za f <br /> J,1S 0QRN� UlYrtr , <br /> tr/ Number Direction / i Street Name Cif 2I Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slreel Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 f EXT. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> 5 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO / <br /> +�� . . / CHECK If BILLING ADDRESS <br /> v <br /> Wl /� OIIJ <br /> BUSINESS NAME , PHONE # EXT. <br /> LSO , LJ <br /> HOME or MAILING ADDRESS /1 FAX # <br /> CITY `'-' STATE 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 <br /> or 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 FED 'IU L IaWS . / <br /> APPLICANT'S SIGNATURE : _ DATE. /O ZZ/ <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGEN CG'/jS�l ".Cr]C✓ /� "�GjC �� <br /> If APPLICANT i5' no/ the BILLINGPARTY proof of authorization /o sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DPPAR'rMENT as soon as it is available and at the sante tittle it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENT <br /> Wca <br /> CSS l � i � �� (li t? RECEIVE ® sAMP . `Zags <br /> Co <br /> COQ <br /> iEi : T [ Z 2019 McTN� R�R �� <br /> S UIN COUNTY <br /> ACCEPTED BY: EM ONMENTAL DATE: <br /> Pi EPART ENT <br /> ASSIGNED TO: EMPLOYEE #: DATE: CI.i <br /> Date Service Completed If already completed): SERVICE CODE: P I EiI i. <br /> Fee Amount: L j Amount Paid Payment Date <br /> dam _ , 7 <br /> Payment Type Invoice # Check # Received By <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />