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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sapu <br /> OWNER/OPERATOR— <br /> U � LA � CHECK If BILLING ADDRESS <br /> t <br /> FACILITY NAME <br /> SITE DRESS �/� � <br /> Street Number Direction Y StFeet Name Tr� C Zi Code <br /> HOME or MAILING <br /> (�ADORE <br /> (SS�(�If Different from Site Address) <br /> Com' " - Street Number Street Name <br /> CITYr STATE ZIP <br /> 6tC . <br /> PHONE#1 / EXT• APN# LAND USE APPLICATION# <br /> I ( 4)1;6q-6 U-1 <br /> PHONE#TEXT. BIDS DISTRICT LOCATION CODE <br /> L[ _qo( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '� t ` ! CHECK if BILLING ADDRESS <br /> BUSINESS NAME I 1 S lea (, PHONE# EXT. <br /> ( 1 9 R- G <br /> HOME or MAILING ADDRESS FAX# <br /> CITY (V u / 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 /> 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 ATE and FEDERAL I 1 <br /> APPLICANT'S SIGNATURE: DATE:6) " �';2_01 q <br /> PROPERTY/BUSINESS OWNER PE TOR/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 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 as soon as it is available and at the same time it is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I ,S rf PAY ENT <br /> COMMENTS: RECEIVED <br /> dW�� iP Ita. l� 2019 <br /> SAN JOAQUI COUNTY <br /> r <br /> ENVIRONMENTAL <br /> ACCEPTED BY: 1 ( A'/jEMPLOYEE#: DATE: J RTMENT <br /> ASSIGNED TO: � v� , EMPLOYEE#: df— DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: / .o -f <br /> Fee Amount: l Amount Paid l s 2 Payment Date lYt/ <br /> Payment Type (/S ,� Invoice# c4aek# 3 G Z L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �►(�� i�13�3 <br />