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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 I OPERATOR <br /> ,1 r CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Y pp 1I11 ss i� �t c <br /> SITEISVEAADDRESS `1.1��Q t9A q S"ttk:I'� O C� "UoZ la <br /> _ VV�� Street Number Dlrectlon Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different fro Site Address) �{�u <br /> 71 _S/treet Num r Street Name <br /> CITY �C��'b V STATE. ZIP � 1 <br /> PHONE#11 ' (f EXT. APN# LAND USE APPLICATION# rte( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> t Y CHECK If BILLING ADDRESS <br /> .(S 5 <br /> BUSINESS NAME PHONE If EXT. <br /> Y <br /> HOME Or MAILING ADDRESS Fax# <br /> e 5 ( ) <br /> CIN 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 1 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: ex ("�\ Qn C$/T DATE: O�/-171'26 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <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 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 /> 11.111,lwfF <br /> TYPE OF SERVICE REQUESTED: MVI % lvr <br /> COMMENTS: to <br /> AUG 1 1 2020 <br /> SANJOAQENVIRONI N CO 7y <br /> HNLTH D PARThj NT <br /> ACCEPTED BY: ,G v`I ,� J EMPLOYEE#: ✓ DATE: 1� <br /> � <br /> ASSIGNED TO: r EMPLOYEE#: DATE: 11 f <br /> Date Service Completed (if already completed): SERVICE CODE: 000 ,I PIE: r <br /> Fee Amount: �� Amount Paid �—�Q r Payment Date to 2© <br /> Payment Type Invoice <br /> /# Check#te, Received By: <br /> EHD 027/2003 v00lU t t 1 I !�" '`^^� tSR FORM(Golden Rod) <br /> REVISE 11 <br />