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SAN JOAQdTN COUNTY ENVIRONMENTAL HEALTH pEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z/Ou LAOOZZI-7Z 579oo7gvcvC1 <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> z Fl N( <br /> FACILITY NAM FO b _zJo <br /> SITE ADDRESS ZD W U11 /t -, G � VP <br /> StreeNameSheet Nio / <br /> Lt Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ta k rte'/•e— <br /> / p ' I �' Q�✓c Street Number �( Street Name <br /> CITY STATE ^ ZIP C S z I <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (z ) S g- 2 z6 <br /> PHO E#2 EXT. BOS DISTRICT LOCATION CODE <br /> (z ) r_ 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR % Ar1 ^ CHECK If BILLING ADDRESSQ <br /> BUSINESS NAME �`rL'L [• PRp # EXT. <br /> 77, 72YOGf Lo —ZZ <br /> HOME or MAILING ADDRESS /�� ^/�`/� (Ax# ) <br /> 8 o /n g2 ( C <br /> CITY L.,c STATE C 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 We 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 SIGNATU rRrEE: !y DATE: 117- Z-916 <br /> PROPERTY/BUSINESS OWNER IqI 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, 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It Is available and at the same time It Is provided t0 me or <br /> my representative. PMMENI <br /> /�,,�, <br /> TYPE OF SERVICE REQUESTED: -rood C/�r ��jl��� <br /> RECEIVED <br /> COMMENTS: <br /> JAN 27 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE:of/.2'I[1� <br /> ASSIGNED TO: EMPLOYEE#: DATE]61 0-1/110 <br /> Date Service Completed (if already completed): SERVICE Cooe P I E: 11N�0Z <br /> Fee Amount: ,CrO Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />