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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA- Cob ls6s' �Gt b 07P-7-71 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS UCA�Iri <br /> Slreet Number DI�reVV o -" �- V r`S—treel Name cityZI Cotle <br /> HOME Or MAILING ADDRESS (If DifffferrennIt from Site Address) <br /> V(/t/ r Street Number Street Name <br /> CITSTATE✓ ` APPLICATION <br /> �J ZIP STATE � l <br /> PHONE#1 �C/r ` APN# li LAND USE APPLICATION# <br /> (`I) OISZ `2-13 � <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> ilG'I ) <br /> 40S 14`il <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Py.ONE# <br /> HOME or MAILING ADDRE FAX# <br /> I C4 01 <br /> V1 l ( ) <br /> CITY Ci� STATE 66 <br /> zip e5TIS"'2,10 <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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard , TATE a VJ�7 <br /> �/1 <br /> APPLICANT'S SIGNATURE: DATE: Z r - 1b <br /> PROPERTY I BUSINESS OWNEROV OPERAT R/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, 1, 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 asgmEa ent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same timet IS� ` fp� <br /> (aa Or <br /> my representative. /" --``ry <br /> TYPE OF SERVICE REQUESTED: ` Ia F c/ ON K D <br /> COMMENTS: 2018 <br /> N'T JN <br /> M 01VWUNty <br /> AARTMNT <br /> ACCEPTED BY: T 106re( " EMPLOYEE#: R!uv'1 DATE: 'a/,IASSIGNEE)TO: 1 M C h 1 EMPLOYEE#: l33I DATE. p/pal I Af <br /> Date Service Completed (if already completed): SERVICE CODE: P 15: (F <br /> Fee Amount: ��� Amount Pai �r Q6P Payment Date <br /> Payment Type Invoice# Check# � ,Z3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />