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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> \�e 15 , IJNIJx 01 A 0020 00 12-CO <br /> OWNER/OPERATOR <br /> E CIL V, p� ,11O5o 6le`-1—C Z CHECK If BILLING ADDRESS <br /> FACILITY NAME 7SCOOS ► cvt'oan �Pc)oa <br /> SITE ADDRESS 2 S 4 SSP S. S Z� • � �c� G1 3 7 <br /> Street Number Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S Gi L u� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Oob) C�a 3 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ] m e-0 1(1 0S r 0 CHECK If BILLING ADDRESS <br /> BUSINESS NAME (�T -` PH E _3,0 �O EXT. <br /> M2X(C'(1V-1 1oo <br /> HOME or MLING ADDRESS FAX# <br /> c 7V l L ( ) <br /> CITY r�C STATE CA ZIP 9531 <br /> BILLING A OWLEDGEMENT: 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 <br /> or 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. <br /> APPLICANT'S SIGNATURE: �7/r2 /vG/� _ DATE: V'7 1I <br /> //� <br /> PROPERTY/ USINESS 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> ( ,,I "�� <br /> TYPE OF SERVICE REQUESTED: � V\vl� d� �v��Uv �L RECEIVED <br /> COMMENTS: <br /> C'a.�l -b S�1���,�e - � SEP 2 5 2019 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: y, � � EMPLOYEE#: DATE: q <br /> ASSIGNED TO: y-, 1�/1 EMPLOYEE#: DATE: t ll <br /> Date Service Completed (if already completed): SERVICE CODE: Vu P I E: <br /> Fee Amount: 1 C52 f Amount Paid l 5 2 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 n/) ,t 2 3 uq 15 <br />