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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Busiine{ss or Property <br />FACILITY ID # <br />PHONE# EXT. <br />,lgz- bS�b <br />SERVICE REQUEST # <br />7Wlt7Ol qle d' <br />CITY G� 1—, STATE C/t- ZIP <br />��r F_ 0U 7� <br />OWNER (OPERATOR <br />6?a <br />CHECK if BILLING ADDRESS <br />Pane- FACILITY NAME Pa- l Ja-171 J7 J- ;5I <br />SITE ADDRESS -?,:2_0C> <br />i^'l r 1G r I <br />ASSIGNED TO: <br />�j�oG iG( C� <br /><✓�'� % a <br />Street N .J DFreetion <br />Street Name <br />CI <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Amount Paidl� <br />!J 7,hey-him &=A dtl�t' Street Number <br />Street Name <br />CITY S --hoc lc 7t <br />"�'vyl, <br />STATE ZIP 176%Z 0 <br />PHONE #1 E)rT• <br />(201)�t�a.-bS9b <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />c �b7q-lobes <br />OS DISTRICT <br />F <br />CATION CODE <br />Fo <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR G�abt�ie� �irJ1�v1 CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME � <br />PHONE# EXT. <br />,lgz- bS�b <br />HOME or MAILING ADDRESS 7973��� �� 1 �u, Ar - <br />FAX # <br />CITY G� 1—, STATE C/t- 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST E and FEDERAL laws <br />APPLICANT'S SIGNATURE: �. DATE: <br />PROPERTY / BUSINESS OWNER © OPERATOR/ MANAGER Ad 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 a5 it is available and at the same time It Is provided to me or <br />my representative. ma -4 ACPAT <br />TYPE OF SERVICE REQUESTED: TW_6� F f alf, <br />(ED <br />COMMENTS: - <br />DEC 14 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMIENTAL <br />IHFALTH DEPARTMENT <br />ACCEPTED BY:�fh <br />EMPLOYEE#: <br />DATE: 2 f <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: [;?-r <br />2Date <br />DateService Completed (if a ready Completed): <br />SERVICE CODE: L�2_ "J ' � <br />PIE: n <br />Fee Amount: <br />Amount Paidl� <br />• CD <br />Payment Date 1 ;k,' <br />Payment Type V S <br />Invoice # <br />6heclF# a a 2 G Received By: <br />�.e l <br />EHD 48-02-025 5R FORM (Golden Rad) <br />07117108 <br />