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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> Ovv -75�(o 11 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME A ) <br /> lIhA (V <br /> SITE ADDRESS g'',//�//T S <br /> 'Street Number Dlrecllon ' 4( Street Nama ��D��I ZI Coda <br /> —HOME or MAILING ADDRESS (If Different from Site Address) <br /> Lti Street Number Street Herne <br /> CITY STATE ZIP <br /> PHONEA E)rT• APN# LAND USE APPLICATION# <br /> rz©1) 23 <br /> PHONE#2 EaT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAMEPHONE# Ext. <br /> 1>' ' 2, <br /> HOME or MAILING ADDRESSFAX# <br /> ` L ( ) <br /> CITY S STATE ZIP ( tz <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _� i�/� DATE:�L :27 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is nal the BLLLLNG 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 environm nIt U ' e assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ImTe it IS <br /> provided to me or my representative. R / <br /> TYPE OF SERVICE REQUESTED: I a l n �JVEO <br /> COMMENTS: 2021 <br /> SAN jOA <br /> H ENVIRONM COUNT <br /> E9liypFPf OL T <br /> n 4 vIC,K C4 0/`/ <br /> ACCEPTED BY: ,�/1 EMPLOYEE#: v DATE: <br /> ASSIGNED TO: Vl• EMPLOYEE#; �t DATE: L 2v <br /> Date Service Completed (if already completed): SERVICE CODE: V PIE: LPO <br /> Fee Amount: .W I Amount Paid 15 2t Payment Date (2-3f2-f <br /> Payment Type invoice# Check# Received By: UL`r7d� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />