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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />REQUEST # <br />FAx# <br />( ) <br />CITY STATE ZIP <br />G r G � -!5r5— I <br />�- 2 u. I <br />SSERVICE <br />OWNER / OPERATOR <br />j .t <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />L <br />�.L <br />�fV�LVit Z <br />5 �D C <br />SITE ADDRESS I it�C.(. <br />I <br />L�-S�t'reat <br />Ville— <br />r_ <br />Street Number <br />Direction <br />DATE: <br />Name <br />ASSIGNED TO: i� Y-p�� <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) Jaw <br />- <br />completed): <br />Street Number <br />PIE: EL B. Z <br />Street Name <br />CITY <br />Amount Paiwiso, pj> <br />STATE ZIP <br />PHONE#1 Exr. <br />qcq)— <br />APN#LAND <br />I 04L k L(i _ <br />USE APPLICATION# <br />PHONE#2 ExT. <br />( ) — <br />Check # <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS El <br />BUSINESS NAME <br />PHONE # ExT. <br />HOME or MAILING ADDRESS <br />FAx# <br />( ) <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 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 <br />DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it Is available and at the Same time It IS provided to me Or <br />my representative. <br />T ft"MUESTED: <br />D <br />G r G � -!5r5— I <br />�- 2 u. I <br />MAR 12 2015 <br />JOAQUIN COUNTY v <br />AN <br />ENVIROMENTAL <br />I EPARTMENf <br />HEALTH <br />ACCEPTED BY: CL,w <br />r_ <br />EMPLOYEEM <br />DATE: <br />x ( t <br />ASSIGNED TO: i� Y-p�� <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already <br />completed): <br />SERVICE CODE: <br />PIE: EL B. Z <br />Fee Amount: I N <br />Amount Paiwiso, pj> <br />Payment Date 3 <br />/S <br />Payment Type <br />Invoice # <br />Check # <br />Received By: 6* <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />