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SAN JOAQUIWOUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2 5 j ` — -- O cS �—'� "� •� \�'„ :� <br /> Street Number Direction Street Name Ci ICI'5Zi2 ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (2-0) Lk b 5 ovs P-6-7r <br /> PHONE#2 EXT• BOS DISTRICT j LOCA-nCODE <br /> ( ) <br /> C>() <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PA <br /> (` CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> c_V--.v\- Cola,. SA0� e. zap �l oro <br /> HOME or MAILING ADDRESS FAX# <br /> 905 C1131i ( Gg ) 183e — LfC` 4 <br /> CITY F:S��l a STATE UAI ZIP 9 <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,STA F E laws. <br /> APPLICANT'S SIGNATURE: DATE: i(Y' <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ®\V P_C CGy' �^�� ��C�t�,$FW✓V�.� <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 <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 andt the same time it is A <br /> provided to me or my representative. /"�Y4 <br /> TYPE OF SERVICE REQUESTED: cl ye— <br /> COMMENTS: SEP ®5 2017 <br /> SJOAQUI <br /> AMRON N SOU TY <br /> HEALTH OSpgRT NT <br /> ACCEPTED BY: ��A _. EMPLOYEE#: 2 �� DATE: <br /> ASSIGNED TO: EMPLOYEE#: 79�1 DATE: l' <br /> Date Service Completed (if already completed): SERVICE CODE: �j(o/ P I E: - ' t) <br /> Fee Amount: '� Amount Pa l� Payment Date <br /> Payment Type C Invoice# Check# �, 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />