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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR <br /> ^1 �:) CHECK If BILLING ADDRESS <br /> FACILITY NAME V <br /> i <br /> ^S <br /> SITE ADDRESS s <br /> �ireet NumberDirection IlSle! ama� CI ZI Cotle <br /> HOME or MAILING ADDRFxS f DI=from Site Address) <br /> UoL 11�J U � Streat Number Street Name <br /> fi STA ZIP �C <br /> � n J <br /> PHONE IlEXT. APN# LAN USE APPLICATION# <br /> 0!5 � - 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRE55E] <br /> BUSINESS NAME LJ/�l PHONE III <br /> HO -OZf%LIb[GDDR SL - 'Ax# ) <br /> CITY �i/ STATE ZIP S��9 <br /> BILLING ACKNOWLE GEMENT: 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 <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, STATE a FED aw . <br /> APPLICANT'S SIGNATURE: DATE: v v <br /> PROPERTY/BUSINESS OWNE TOR/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, 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 t0 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: F e PAY <br /> MENT <br /> COMMENTS: <br /> AUG 0 4 2020 <br /> SAN JOAQUIN COUNT' <br /> ENVIRONMENTAL <br /> HEA)JH DEPARTMEN <br /> ACCEPTED BY: 7W I <br /> EMPLOYEE#: CA, <br /> � DATE: 2� <br /> ASSIGNEDTO: ,r EMPLOYEE#: a. DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 'P 1 <br /> Fee Amount: Amount Paid G�^ Z _ Payment Date l <br /> Payment Type Invoice# Check# Received(By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />