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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/OPERAjO(2 \ qv\ ���", ^ <br /> `- ('�,I,n r\ -1 CHECK IT BILLING ADDRESS <br /> FACIL NAME <br /> SRE ADDRESS Q3'JJ(� 11 / <br /> Street Numb_e/r Direction G •7, )\SlreetONa-mt�e CS CIW1ZI Cotle <br /> HOME or MAILING ADDRESS Af Dllfflrent from Site Address) tp/I j /r i se 11 Q �� <br /> 1 1 Street 4. er ✓I l- Street Name <br /> CITY �1/ Lbw ST TE ZIP <br /> PHONE#1 EI'T• APN# LAND USE APPLICATION# O <br /> (sem) l4 <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i�m(f1 n <br /> 'r `}t CHECK If BILLING ADDRESS� <br /> BUSINESS NAME5>kof 1314 C /l f PHONE# EXT. <br /> HOME or MAILING ADDRESS 2-q / +$e//'(/`(p ` FAx 1 n^ /_g <br /> CITY C�-/Y'k,r�•O,n -avk STATE ZIP 5.7 n <br /> BILLING✓I ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent <br /> geent of same, <br /> acknowledge that all site and/or project specific ENVI NMENTAL HEALTH DEPARTMENT hourly Charges associated with this project <br /> or activity will be billed to me or my busin as identi d on this form. <br /> I also certify that I have prepared this appli ti n and t a the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT d FE laws. G, q <br /> _APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATO ANAGER ❑ OTHERAUTHORizED AGENT❑ <br /> IfAPPGCANT is not the BILLING PARTY Proof of authorization to sign is required Titte <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[ �yttime It iS <br /> provided to me or my representative. fik <br /> ENV- <br /> TYPE OF SERVICE REQUESTED: 0�- VF <br /> COMMENTS: 5 2Q19 <br /> JOqQU <br /> ZJV <br /> rf/1 1^ G� GIN�e� � 7 yTHpf MFyrAuL' <br /> JY <br /> �v �TMFNT <br /> ACCEPTED BY: ra EMPLOYEE M/' (/7 /� DATE: Q 5 19 <br /> ASSIGNED TO: r EMPLOYEE M _t �l q <br /> DATE: I 6; /GI <br /> Date Service Completed (If already completed): SERVICE CODE: P I E:! <br /> Fee Amoun : 0 Amount Paid ����rJ Payment Date t� <br /> Payment Type Invoice# Check# 111�2- Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />