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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gel <br /> OWNER/OPERATOR p r� <br /> t,4a,",HECK If BILLING ADDRESS <br /> FACILITY NAME n oil 01- r 1, <br /> SITE ADDRESS V 1 S Cr <br /> I�✓Y,,WDnrv��' <br /> �o' Street Number D e Ion a treet Name 1 v �O h ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t Street Number Street Name <br /> CITY 5I V G A STATE C ZIP YS 2 / <br /> 15 <br /> PHONE#1 fO (� I V EXT. APN# LAND USE APPLICATION# � <br /> (2oq) 2�y9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> J u�� Irf A�✓I vi, CHECK if BILLING ADDRESS <br /> BUSINESS NAME6l na Pto? t6_ Ex <br /> T.HOME or MAILING ADDRESS // ll FAX# J <br /> a) de I MCA a V- 1 I <br /> CITY 9C.K10✓V STATE A ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ] LJ Ct✓\ cq/t'✓l DATE:� �� 2 U Z O <br /> PROPERTY/BUSINESS OWNFAD'y t OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> FfAPPLICANT 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 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: <br /> COMMENTS: <br /> SEP 0 3 2020 <br /> �R <br /> QOUINCOUNTY <br /> Hit-TF1 DE�TTAL <br /> ACCEPTED BY: ( ' EMPLOYEE#: VtQ DATE: C1 3 <br /> ASSIGNED TO: ( EMPLOYEE#: [� DATE: ITI 3 n .l <br /> Date Service Completed (if already completed): SERVICECODE: PIE. �1903 <br /> Fee Amount 5�do Amount Pa' �c.�pl � Payment Date T c3 2D <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />