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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW R/OP OR <br /> L'(---r77 <br /> p �/,1(7-x7 /�o G) CHECK If BILLING ADDRESS <br /> FACILITY NAME 9�i Lck'7C- t p`J� r� ^[��571�� 0 � <br /> SITE ADDRESS (_ 0� <br /> ��Mrn�stre, <br /> lC��eel Number Direction t Name ` Cit ( lye Zip de <br /> HOME Or M LING�ADDRESS (If Different from Site Address/)/ <br /> Street Number Street Name <br /> CITY�i \ �STATE �2/ <br /> PHONE#t v I`J EIT• APN# LAND USE APPLICATION# <br /> PHONE#2EXT• Co BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I)rwov It) '2 Z CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> til i L(, �� Lf�.u�D� � � <br /> HOME or MAILING ADDRESS FAX# <br /> Lo?07 tit l�I S C-- ( ) <br /> CITY l STATE C 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 /> 1 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 s. <br /> T�-PPLICANT'S SIGNATUR l DATE:E- Cg- 2 0 <br /> ROPERTY/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, 1, 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 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: <br /> 3 � . avow -� pin-P �y r 70 1 � MAR 0 6 2020 <br /> NJOA <br /> V1RO)v a OUNTV <br /> H 1H DE All <br /> ACCEPTED BY: C-, Q p� EMPLOYEE#: DATE: S -2 -2�`\ <br /> ASSIGNED TO: C \� EMPLOYEE#: DATE: 3 � 2v <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: �G)�,013 1 Amount Paid Payment Date <br /> Payment Type j _ Invoice# Check# Received By;� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />