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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/OPERATOR <br /> O S 'Z— CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> � SC � or <br /> SITE ADDRESS <br /> Street Number Direction Street Name CIV <br /> / I ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1610 (,/, }-- f a r n s� <br /> Street Number Street Name- <br /> CITY <br /> a eCITY �p STATE ZIP <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> PHONE#2 EXT" BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME ` II A I' PHONE# EXT. <br /> FS C c� 'c�h T ��J ul °-ht»'1 at <br /> HOME or MA�l�ADDR�S,S I FAx# <br /> CITY PA &-,-, 4-,-- C L STATE ZIP Cj 3 3� <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, STATE a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �'I 2 2 v <br /> PROPERTY/BUSINESS OWNERP OPERA /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLI G 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C V\ O� C) 3 "�Q-" REC <br /> COMMENTS: fi q UG <br /> 3 <br /> 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Lyt EMPLOYEE M / ) DATE: <br /> ASSIGNED TO: V ` EMPLOYEE#: vvv DATE: US� :3/ <br /> Date Service Completed (if already completed): SERVICE CODE: G 1 E: U'Z <br /> Fee AmountAll Amount: <br /> v Amount Paid :, Payment Date <br /> Payment Type Invoice# 7Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 S2A2 <br />