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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ ST# <br /> boao 3 0() <br /> OWNER/OPERATOR <br /> (� CHECK if BILLING ADDRESS <br /> FACILITY NAME l , V r c, U c _LNC <br /> SITE ADDARES �AJ <br /> IT <br /> Street Number Direction 1 V�Qtreet Name ✓ - Ci Zi Code <br /> HOME Or MAILINGADDRESS (`'\)f Different from Site Address) <br /> W �• r'l�T' street Number T Street Name <br /> CITYC� 7)k) $TAT€, ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• _ BOS DISTRICT LOCATION CODE <br /> ( JOO C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C <br /> r '\ / CHECK If BILLING ADDRESS <br /> BUSINESS NAME / ,/ PHONE# EXT. <br /> HOME or MAILING FAX#tAJ ) - s-'-:;! <br /> CITY (`/ -)j7,J STATE ZIP s,-;)OL;)y5L <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, Standards and F E L laws. I- <br /> APPLICANT'S SIGNATURE: � DATE: [D <br /> PROPERTY I 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 <br /> site address, hereby authorize the release of any and all 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 l��gvided to me or <br /> my representative. lel <br /> TYPE OF SERVICE REQUESTED: Ge(�S CSI 1 CEIV <br /> COMMENTS: OCT 0 <br /> 3 2018 <br /> SAN O `% V t RONN COUNTY <br /> 1 <br /> HEALTH pEpgRTMEAIT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I c �cX� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />