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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �fl O7 ( 7 4 0/ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t>T�L� R <br /> S126000 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME n/ q <br /> SITE ADDRESS (� <br /> S 11 1iN <br /> S Street Number D rec to / "I/j a He /1 I (J 1- Zlo Code I <br /> HOME or MAILING ADDRESS (If Different from Site Address) II <br /> dl9 Street Number Street Name <br /> CITYSTCA ZIP <br /> ^^ Ph <br /> �2 <br /> G/V, V J b <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> X31) /Z&AJ :/ OM.t'I r I L <br /> PHONE#2 FXT. BOB DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ke <br /> Y <br /> V�1 CHECK II BILLING ADDRESS <br /> BUSINESS NAME I PHONE# En. <br /> ( V E A5 3s I 0\"1I -eey r <br /> HOME or MAILING ADDRESS FAx# <br /> CITY _57CL 111A STATE If ZIP '736`2 <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 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,S N11 <br /> and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; 4IaD2D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Vr/lvC <br /> If APPLICANT 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. PAVAVpA I., <br /> TYPE OF SERVICE REQUESTED: /p ��Gl.tn 1.� �, REC <br /> COMMENTS: \ w '- <br /> SAN 03J Q 5 2020 <br /> VIjRONt N <br /> ENCOUNTY <br /> HEALTH pEOARTMEI. <br /> NT <br /> ACCEPTED BY: 1 0 S EMPLOYEE#: �/ DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: �l/� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 11 P I E: <br /> Fee Amount: Amount Paid Payment Date '? 5 [) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />