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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propertyx FACILITY Id# SERVICE REQUEST# <br /> ce&-lee- I I A "1. 4 1 PAM SE U�) <br /> OWNER 1 PERATOI CHECK if$ILLIN� G ADDRE� <br /> 54 <br /> FACILITY NAMV yp <br /> 1 y <br /> SITL ADDRESSX X 10 e- <br /> /f Streer('lame CG Z7 Code <br /> !/ Street Number Dkection <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Na <br /> STATE <br /> CITY <br /> PHONE#1 ExT. APN# LAND USE APPLICATION 10 JAN 18 2019 <br /> T- BOS DISTRICT LOCATION CO E <br /> PHONEZ <br /> L'NVIRO NIENTAHE LTH <br /> { ) r l <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR CHECK If$1 LLING ADDRESS <br /> PIiom# ExT. <br /> BUSINESS NAME ) <br /> FAX# <br /> HOME Or MAILING ADDRESS - ) <br /> STATE zip <br /> CITY <br /> BILLING ACKNOWLEIGEMENT: I, the undersigned property.or business owner, operator or authorized agent of same, <br /> acknowiedge that all site and/or project specific ENIARONMENTAL 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 /> 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 SIGNATUREAC,--"6 DATE: <br /> PROPERTY f BUSINESS OWNER❑ OPERATOR t MANAGER ❑ OTHER AUTHORIZED AGENTTitle <br /> if APPLICANT is riot the BiLLI G PART proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFDRMATIOnt: VVhcn applioabc, I, the owner or opQratnr of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environrnentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as so a5 It 1S available and at t112 Sarna time 1t Is provided to- Or <br /> if <br /> my representative. <br /> f� 6<Jj <br /> rTYPEOF SERVICE REQUESTED:ENTS:o /11 S�GE-4 'C'4L� ' CV V do. <br /> f V <br /> / Eyo. 0�9 <br /> 1 D /i S 1 4 h —4�1rHD�NNr N <br /> EMPLOYEE#: ��� DATE: <br /> ACCEPTED BY: L <br /> EMPLOYEE#: DATE: /( <br /> ASSIGNED To: � ,���L �� <br /> Date Service Completed (if already completed): <br /> $ER%ItCE CODE: P 1 4 <br /> Fee Amount: <br /> Amount Paid -` .06 Payment Date <br /> payment Type <br /> Invoice# Check# S Ree Ive By: <br /> SR FORM(Golden Rad) <br /> EHD 48-02-025 <br /> 07117/08 <br />