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SAN JOAQVCOUNTY ENVIRONMENTAL HEALTH PIPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S?-oo787? S <br /> OWNER/OPERATOR t� /)�t ��,fv�I CHECK if BILLING ADDRESS <br /> FACILITY NAME o�,( � (/,�y� ` l 6 � A <br /> SITE ADDRESS VVI U 15 vu'0 (�J �L A IZf�t � <br /> Street Number Direction Street Name Ci Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 7 EXT, BOS DISTRICTLOCATION CODE <br /> w( CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 64 cfv <br /> S , / CHECK if BILLING ADDRESS <br /> BUSINESS NAME V PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that th_Q work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FED aws. ,) <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPER /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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVE® <br /> COMMENTS: t't8 U 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: c-7� EMPLOYEE#: DATE: 9 GY <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ( �g� Amount Paid Payment Date e} A <br /> Payment Type C Invoice# Check# Received By: <br /> c <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />