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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'FA 00 151011 90- o0g3 ►,.�o <br /> OWNER I OPERATOR <br /> T /y CHECK If BILLING ADDRESS <br /> FACILITY NAME I/v' l 2- 1 y G— <br /> SITE ADDRESS ��I2 Ae +�� % 6 <br /> Street Number Dlrection t'� Street Name �S�fCit" ZigCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) go 3 �; f�n )Y91 t V v <br /> Street Number Street Name V� <br /> CITY <= �A STATE ZIP �^7l <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# L'I <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR 4,n _ --myt CHECK if BILLING ADDRESS C3 <br /> BUSINESS NAME 4D 2 V2 r�n� L PHONE# Ems' <br /> HOME or MAILING ADDRESSFAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, 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, STAT I and FEDERAL S. <br /> APPLICANT'S SIGNATURE: DATE: 1 1 I <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTNER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING G PRRTT 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. l <br /> TYPE OF SERVICE REQUESTED: Lf <br /> COMMENTS: <br /> JAN 2021 <br /> SM JQA0 <br /> Hr� '" 'ulAl kNE4L ' H� <br /> 1JW <br /> ACCEPTED BY: EMPLOYEE#: DATE: —�y-2 <br /> ASSIGNED TO: n J� EMPLOYEE M DATE: <br /> „Date Service Completed (if already completed): SERVICE CODE: P I E; <br /> Fee Amount: 5� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ` N' n�? SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />