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FA DOO 15 Z.-�- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> �AbIL1D# SERVICE REQUEST# <br /> ITY0IS��- <br /> OWNER/OPERATOR n 0 V O 7- <br /> ch u G(fin HLA" "� CHECK if i-LrN�pRESS <br /> FACILITY NAME <br /> SITE ADDRESS22 �//V�ft Q e- <br /> Stree{7 Numb��er! p'reCtn '� <br /> HDMStreet Name CI gor MAILING ADD ESS_(If Different from Site Address) l 1 <br /> Zi Code <br /> Streef Number <br /> _ Sfreet Name <br /> $TATE ZIP Z! Z- <br /> PHONE#1 E%T. u APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 iJ D EXT. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR If SERVICE REQUESTOR <br /> [BUSINESS <br /> QUESTOR <br /> CHECK if BILL NG <br /> NAME PHONE# EXT. <br /> HOME or MAILING DDRE 5 Fax# <br /> e� ( ) <br /> CITY /,4A +OVA STATE zip <br /> BILLING. AC NOW EDGEMENT: 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 farm. <br /> 1 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- �f/,j/ U DATE: y?" <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it' ovided tome or <br /> my representative. <br /> TYPE or SERVICE REQUESTED:` n0a �jtS! �' IV <br /> COMMEt,rs: coq /In_ ,�n n J J 5 MAY Z 5 2017 <br /> (v\ fv/rp �/ �/ ANJOA <br /> IQUInr <br /> ON ILIN <br /> NEALHR SPAR 7AL <br /> AccEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 7jol <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: 3`1 U Amount Paid 1����� Payment Date s/a57 <br /> Payment Type ._ Invoice# Check# Rece(ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />