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SAN JOAQUI' ` OUNTY ENVIRONMENTAL HEALT'- DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M F x ZOO 6075,Z--" <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> G ' A r <br /> FACILITY NAME <br /> • alt rot", a L - trl rid, <br /> SITE ADDRESS �-' �✓A i� 5 cjc�,i,. A (.� y $Z1-x-/ <br /> 2-U! q0 r <br /> Street Number Direction �• I � Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> OL,/C' Street Number Street Name I <br /> CITY STATE ZIP <br /> -tot-,( f <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (7.al) Y63 �� �f <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ad 151_�4 t Q 4, F7 Z_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME . PHONE# EXT. <br /> HOME or MAILING ADDRESS S r FAx# <br /> CITY S STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 /> 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 FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAOO GER ❑ 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. /� <br /> TYPE OF SERVICE REQUESTED: �(�D� L)ck r GLS (n1Sr�E C-%Z� PAYMENT <br /> REeEIVED <br /> COMMENTS: <br /> AUG 10 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: i_t L/& EMPLOYEEM 0324 DATE: !�AD <br /> ASSIGNED TO: EMPLOYEE#: DATE: !Q CO <br /> Date Service Completed (if already Completed): SERVICE CODE: 0(,,,/ P/E:� lo� <br /> Fee Amount: Z 2 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />