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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b'qdw soop f 1406) a-7 5(ZC67S3"�510 <br /> QV�WER/OPERATOR , <br /> / MIO ,^ q C ECK If BILLING ADDRESS <br /> FACILITY NAME /` _,Yn I „nC I�e� G mm f I�/ I r <br /> SITE ADDRESSn' <br /> W11 15,A <br /> (tea y C s Zn 95a I, <br /> `� S[reet Number Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN Rb Ck- STATE LA -/ ZIP S <br /> PHONE#'I EXT' APN# LAND USE APPLICATION# <br /> (0m) 4t91- a�a� <br /> PHONE © <br /> #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 6 a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR l) <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FA%# <br /> CITY STATE 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 /> 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: &t , 'Y' DATE: <br /> —� <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof of authorization t0 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 tlmeA, �VjC�,�IO rr10 Of <br /> my representative. 0 ft <br /> ��NT <br /> TYPE OF SERVICE REQUESTED: ��. - ED <br /> COMMENTS: OCT 3 0 2017 <br /> Q W o SAN JOAQUIN COUNTY <br /> HEALTH <br /> ENVIRONMENTAL <br /> EPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 10 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> 0' <br /> Date Service Complete already completed): 77FSERVICE CODE: PIE: 2 <br /> Fee Amount: Amount Paid ''— (� Payment Date <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) _ <br /> 07/17/08 —/✓// <br />