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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =SERVICERe { LIY-carp C t0()2(? k7 <br /> OWNER/OPERATOR 'IN C ��ry� CHECK If BILLING ADDRESSO <br /> y� s <br /> -FACIUTv NAME M�,.�S !SITE ADDRESS <br /> e17L / fP S ,//l l� �LZYI �-G�- ZI Code <br /> Street Number Direction Street Name <br /> HOME Or MAILING ADDRESS (If Differentfrom/Site Address) <br /> a <br /> /�/.1 �Y .t['Q eW42i/3V Street Number Street Name <br /> CITY STATE /� ZIP ��03 <br /> �S�JkL,9N D C C <br /> PHONE#� FxT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (ac9l 39 . c9 J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� CHECK If BILLING ADDRESS <br /> /Y PHONE# ExT. <br /> BUSINESS NAME ,fJ� t <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY p.; r4n�er 11 K d/T kL//N/J STATE /, ZIP i/er"'3 <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, Standa:2�� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR 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 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 IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: FUD GU V Vy / <br /> " RiCEIVED <br /> COMMENTS: t I / �l A A�/T Q A� MAY 3 U 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: "it,P-N t l t,/ EMPLOYEE#: DATE: 6/ 30117 <br /> ASSIGNED TO: �I N I I '\� EMPLOYEE#: DATE: C o 17 <br /> Date Service Completed (if already completed): SERVICE CODE: W ( P I E: <br /> Fee Amount: l ,(j Amount Paid I C, - Payment Date - / <br /> Payment Type - - Invoice# Check# - ' Received By: '� C <br /> EHD 48-02-025 it � SR FORM(Golden Rod) <br /> 07/17/08 v( V <br />