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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fb -\- UN- <br /> OWNER i OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction �`Ll" tr'eef NamVe vv- , D 1v Cl'(Jiv, 1 ZI Ca e <br /> HOM�;r AILING ADDRESS (If Different from Site Address) <br /> {t' Street Number Street Name <br /> CITY STATE ZIP <br /> Ca 5—Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> V? ) 60 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR '/� <br /> v ;/1,LPr (�\ �i�1 1.f�1 /��� CHECK If BILLING ADDRESS <br /> BUSINESSNSIME `CIJ�\l/�� `Vl1�t/� PHONE# EXT. <br /> a Y e �2scp - (o �v!v la Aa <br /> HOME Or MAILING ADDRESS FAX# <br /> VIfro U° ( ) <br /> CITY O STATE 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: Rok&P/ 60'1 'Za&' Z DATE: PAYMENT <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required SSP 16 2020 <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environ IyI rN,RIxt <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anA TR117 Tis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: !� yy p G �{ <br /> COMMENTS: �'e I/�'t! C�9L° co M0 r�'� Ip�S Ca 11tU( �0(5J00 ` 0 I/C- <br /> y? Vvdr'ea to h� 'labtt o <br /> ` a5 I Cah �'QS <br /> ig PO des c e Va U0.5 P�' Pr Sr <br /> E clad P <br /> ACCEPTED BY: C-\. EMPLOYEE M DATE: (:7` <br /> ASSIGNED TO: EMPLOYEE M DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: 0i,-Q P I E: \ t <br /> Fee Amount: Op I Amount Paid ( S2 Payment DateIg <br /> ( vD <br /> Payment Type ed Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />