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SAN JOAQ. .N COUNTY ENVIRONMENTAL HEALTH . t!PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID,# <br /> # VICE REQUEST# <br /> Uu2. 1,.,,SER <br /> buy so3� <br /> O. ER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY E f <br /> SITE ADDRESS JYoC�T-� y'Jda,3 <br /> ��U/' n fG.r'/✓1 <br /> Street Number Direction J � ���r Street Name city Zir,Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 91a6,,5- 17391// Street Number Street Name_ <br /> CITY STATE ZIP <br /> PHONE#t T' APN# LAND USE APPLICATION."' <br /> t269l /a3 - ?y72 <br /> PHONE#2 7 EXT. BOS DISTRICT LOCATION CODE <br /> (26?L y✓l' .i G.S� <br /> CONTRACTOR/ SERVICE REQUESTCR <br /> REQUFSTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINES E II PHONE# Ext. <br /> HOME Or MAILING ADDRESS FAX# <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 laWG. <br /> APPLICANT'S SIGNAL RE: TE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 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 l0 Tt7e Ot�e.N� <br /> R <br /> my representative. E(` '�FA <br /> TYPE OF SERVICE REQUESTED: V'Ob, V t S JUN 1 2016 <br /> COMMENTS: SA OIR uit,COUN <br /> HEENVALTH pCPtt NT4L ry <br /> /� TMEw <br /> ACCEPTED BY: r.t OII/1 f't O EMPLOYEE#: DATE: Yl I1 'IQ <br /> ASSIGNED TO: 1` EMPLOYEE#: /,, DATE: V0 ( `11, 1 utu <br /> Date Service Completed (if already completed): . SERVICE CODE: SCOW PIED 1( ;3 <br /> Fee Amount: �it 3 U Amount Paid 13o D D Payment Date (o <br /> Payment Type Invoice# Check# Received By: <br /> 6111 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />