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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OMPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T TTS <br /> OWNER/OPERATOR <br /> ��v/v CHECK if BILLING ADDRESS El <br /> FACILITY NAME ( ,) /,^ C l i� I my , A4(o/—f <br /> SI 714 ESS GOVT C(cl(� bl V(� ]—*�il� ro� �5aOy <br /> Street Number Direction Street Name CI Zi Code <br /> OME or MAILING ADDRESS (If Different from Site Address) <br /> DLII -I Street Number Street Name <br /> CITY- <br /> C�� STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> (Wil L451-3C10 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> rao`t) ud 5 X51 Le(( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <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 or <br /> 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, StandaKOPERATOR <br /> TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l/Yl� DATE: ffPROPERTY/BUSINESS OWNER I 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 ail results, geotechnical data and/or environmental/site assessment information <br /> to 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. <br /> TYPE OF SERVICE REQUESTED: FA MENT <br /> COMMENTS: <br /> NOV-2 8 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C� _ l EMPLOYEE#: 3 - DATE: <br /> ASSIGNED TO: C--L EMPLOYEE M .� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (v PIE: 103 <br /> Fee Amount: `�� Amount Paid 3 9 L' Payment Date t( f 2q// <br /> Payment Type Invoice# Check# Received By: !� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />