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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEQREEQ/UEESSTv# <br /> seoo <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NA �✓ 7 ("/h <br /> vs <br /> SITE ADDRESS &CUq� �USejHG �S33�o <br /> �IIfFY treat Number Direction S et Name CI ZI Code <br /> HDr <br /> �MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> f�caCA 2!g-33f <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> 3/0 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE- <br /> �� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> wt-" r CHECK if BILLING ADDRESS <br /> BUSINESS f4AMEPHONE# EM' <br /> I J-d-"to i?Lfl) el-&� �-& (47 <br /> HO E or MAILING ADDRESS FAx# <br /> c �� Ll 3- ( TS v y �S <br /> CITY CF STATE CA ZIP C <br /> P�;?3-7�j <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 applica ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: d 2-� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLIcANT 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 OSERVICEREQUESTED: PeV1PJ c,-C �;;fi����1 n"Cj fj,ftcete `fir-r-Ylyt �fGr� <br /> COMMENTS: S F'c o i,761 0", . <br /> SEP 18 2020 <br /> 'ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> ACCEPTED BY: EMPLOYEE#: DATE: q11 70 <br /> `Q/d00 <br /> ASSIGNED TO: �C EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: <br /> Fee Amount: (�O Amount Paid Payment Date G, <br /> Payment TypeC .- Invoice# Check# 3 a eceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />