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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L+ Civ tr Is ITV 6 00 0 1\4 o v <br /> OWNER!OPERATOR CHECK if BILLING ADDRESS <br /> C o-w it"un �ao ti✓ <br /> FACILITY NAME � �f J pe I')'1 I 1 " <br /> SfrrE � <br /> �IADDRESS o�� Y1�t r � i"��� <br /> _14 2) Street Number I Directlon Street Name citi . <br /> Zip Code <br /> HOME of MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY STATE LP <br /> PHONE#1 E A IN# LAND USE APPLICATION# <br /> —7:ill <br /> PHONE#7 ExT• BOG DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESIOR CHECK If BILLING ADDRESS <br /> PHONE# }, ExT. <br /> BUSINESS NAME �� <br /> HOME or MAILING ADDRESS FAX# <br />{` <br /> STATE, <br /> P- <br /> S P- <br /> BILLING A KNOWLEDGEMIH'.l�T: I, the undersigned property or business owner, operator or authorized agent of same, <br /> aclaiowledge that all site and/or project specific ENvIRONMEN'TAL HEALTH DEPART ENT 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 /> COLwN Ordinance Codes,Standards,STATE and FF, RAL laws. <br /> P&PLICANT'S SIGNATURE: DATE: <br /> PROPERTY i BusmESs OWNER Li0 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT <br /> IfAPPLIC4NT is not the_BILLhVGPARTY proof of authorization to sign is required Tate <br /> AUTHORIZATION TO RELEASE ORMATI N: When applicable, I,the owner or operator of the property located at the <br /> above_site.address;Yhereby�,authorize<the..releasewof any�and,all,:results,,geotechnical,data.and/or.environmental/site assessment <br /> information to the SAN JoAQUIN COU NW ENvIRONwNTAL HEALTH DEPARTIvmENT as soon as it is available and at the same time'it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C h ri u Ov PAYMENT <br /> AYMENT <br /> COMMENTS: RECE <br /> t JUL 2 62017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HMTH DEPART ENT <br /> EMPLOYEE M DATE: <br /> ACCEPTED BY: <br /> EMPLOYEE M DATE: <br /> ASSIGNED TO: Ll VllilLl� <br /> Date Service Completed (It already completed): <br /> SERVICE CODE: P 1 E. <br /> r S`L "' <br /> Payment Date 1 2 C <br /> Fee Amount: Amount Paid o L <br /> y Ty �� Invoice# Check# 1d iL Received By: <br /> Payment pe <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />