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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property s FACILITY ID# AERVICE REQUEST# <br /> OWNER/OPERATOR �/ ,�� <br /> . CHECK If BILLING ADDRESS <br /> FACILITY NAME `— N 7 <br /> SIT ADDRESS I /v �s � ) <br /> 16 Street Number Direction Street Name I Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> (J L� Street Number treet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> Qcr) 3 <br /> 7-L— 2-1 e <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` <br /> L CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' PHONE# EXT. <br /> HOME or MAILING ADDRESS !� FAX# <br /> a/ l4el J itt/_"eq ( ) <br /> CITY — c�TATE 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, Standards, STATE and FEDERAL laws. L' <br /> APPLICANT'S SIGNATURE: o" DATE: ✓ "Y /��� ��� <br /> PROPERTY/BUSINESS OWNER❑ OPERAT4R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirie <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 to me Or <br /> my representative. PA <br /> /'r ,,C, <br /> TYPE OF SERVICE REQUESTED: (/VN <br /> COMMENTS: <br /> APR D <br /> %'/0 ,5 2019 <br /> y F RpV�Nc <br /> �TH p HMFH UN)Y <br /> FpgRT G <br /> ACCEPTED BY: EMPLOYEE#: �7� DATE: W0516 <br /> �HT <br /> ASSIGNED TO: EMPLOYEE#: ✓ DATE: /// <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 00 Amount Pai D� Payment Date <br /> Payment Type 0Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />