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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L"2�24'3 S'P—CO8-43cl(T, <br /> OWNER/OPERATOR , 1 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 111 111 l <br /> 1 Cll <br /> SITE ADDRESS , Street <br /> � C 5 2 <br /> t 1 Number Direction SGCI�ca Street Name ����1 city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 2 5mber a <br /> C r <br /> Street Nul C1(A Street Name <br /> CITY I U vv I„ UV P STATE ZIP <br /> C � ot 5 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> C2 cl A 20\ D 0 ?�' <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 06(r Wfe L ,1,1 h1 <br /> 1 V 1 IN CHECK If BILLING ADDRESS <br /> BUSINESS NAME �I PHONE# EXT• <br /> T I J <br /> HOME or MAILING ADDRESS FAX# <br /> 2 C i' ( ) <br /> CITY STATE C ZIP EMAIL <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 activity <br /> 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 �e performed will be done in accordance with all SAN JOAQUIN' <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: " S( L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provi to me Or my <br /> representative. q y <br /> TYPE OF SERVICE REQUESTED: ch Cc k OF obt li ij lUl-) CF <br /> COMMENTS: NOV D <br /> 6 <br /> 'AlvH daR QU/N CO 023 <br /> MFNT <br /> ACCEPTEDBY:i&rin-nkLQ /'W. EMPLOYEE#: DATE: <br /> ASSIGNED TO: r�a h L/S GU K . EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CL6- / P/E: /603 <br /> Fee Amount: j Amount Paid " OD Payment Date G 23 <br /> Payment Type Invoice# Check# /S Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22123 <br /> TRD5"AtP;23 <br />