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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ���FACILITY ID# SERVICE REQUEST# <br /> CL)TGt ` (r( (,Jl rJL`r7 (/�� t <br /> OWNER/OPERATOR <br /> -� (,/,, -�`tj/I C,� '„ n CHECK If BILLING ADDRESS <br /> FACILITY NAME Vi , 'jc <br /> SITE ADDRESS <br /> tu21 , "� l-7 17') m 4 <br /> l <br /> Zip Code J <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> F, lfwy <br /> Street Number Street Name <br /> CITY. STATE ZIP <br /> lI( PC V� C�� '�5 56 <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> ( U — <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR-- CHECK if BILLING ADDRESS E] <br /> t:�: (t'v 1A C 6i CZ C,t <br /> BUSINESS NAME �]&r t PHONE# EXT. <br /> ( ( SV G' Z-� `—74ci <br /> HOME or MAILING ADDRESS FAX# <br /> .Z . o ( ) <br /> CITY l STATE 'A ZIP(::i E7— <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, STATE and FEDERAL*W / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> APR 12 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ' A EMPLOYEE#: DATE: <br /> ASSIGNED TO: V 6 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /111E: 1(V02 <br /> Fee Amount: 60Amount Paid J S� — Payment Date f <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />