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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY/! ^# SERVICE REQUEST# <br /> 'TLY 74K;t- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �`\ 1 i t <br /> ic <br /> SITE ADDRESS \ j/�t V` S vC on <br /> C� C'1 ..1 <br /> 6 Street Number Olmetian I�I ' Street Name Cit 1 JZIOfd) <br /> HOMEor AILING ADDRESS (If Different from Site Address) <br /> S Street Number <br /> Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> (2o1 ) 2� -D )Un <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> l ) SUn <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex. <br /> HOME or MAILING ADDRESS FAX# <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 SIN that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE L laws. <br /> APPLICANT'S SIGNATURE: �� DATE: �� rd' " III <br /> PROPERTY/BUSINESS OWNERLI 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,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and allaesnits, geotechnical data and/or environmentalIsj4 assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as,it is available and at the ary�s� <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 2021 <br /> SANjQEAFV1AQUIN CO <br /> MST H £�MFIYT <br /> ACCEPTED BY: V^ C EMPLOYEE#: O DATE: <br /> ASSIGNED TO: Ma <br /> 1r V EMPLOYEE#: �O3 DATE: 4 ID ?.I <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: UjU,2 <br /> Fee Amount: 15� •Q Amount Paid ' I5a i Payment Date 81ID12-4 <br /> Payment Type Invoice# 2 8°t TL.V I Received By: <br /> EHD 46-02-025 v SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> Quo ILOA ZS <br />