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SAN JOAQQCOUNTY ENVIRONMENTAL HEALTHOPPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ll <br /> OWNER/OPERATOR V0 aI <br /> 11 &�Cist-r T`I r0 -f `)w". CHECK if BILLING ADDRESS <br /> FACILITY NAME ff I� <br /> Ci 1� c ct° ti C kc'AcY C'dIodC <br /> SITE ADDRESS /S pI C � W <br /> Street Number Direction Street Name --- city Zip Code <br /> HOME Or MAILING ADDRESS fif Different from Site Address')- <br /> ITZ rrli w West Ci,C M( Street Number Street Name <br /> CITY STATEO C ZIP <br /> S A-10C-kk- � Ci If?49 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (zoro 93 <br /> PHONE#2 EXT. BOS D TRICT LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Q I Fe4t (2,!:rf y3 17 cls <br /> HOME or MAILING ADDRES _ _ ) ) FAX# <br /> CITY [ G;� j _ STATE L �J ZIP �5 U�r <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 F <br /> APPLICANT'S SIGNATU DATE: �Zl i// /? <br /> PROPERTY I BUSINESS OWNER❑ PERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS riot 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: t PAYMENT <br /> COMMENTS: <br /> CEC G 4 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: \ I u'i tJ� EMPLOYEE#: / DATE: �2 <br /> ASSIGNED TO: V C ,/ EMPLOYEE#: ` DATE: rl <br /> Date Service Completed (if already completed): V SERVICE CODE: 1 b P I E: / <br /> Fee Amount: CD 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 />