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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of s or Propert FACILITY ID# SERVICE REQUEST# <br /> -nuY Fl=y Uvto 59 S R 00-T y(-0 <br /> OWNER/OPERATOR <br /> r-6 r CHECK if BILLING ADDRESS <br /> FACILITY NAME S Q y 0 r, <br /> SITE ADDRESS01 <br /> 1 ` Street Number Direction 9treel Naha Cltv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) _ �p Hyl; t <br /> SireeTNumber ll , ' / Stree <br /> t Name <br /> CITY STATE ZIP `� 2 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) C- _42231vzi ! <br /> PHONE#2 ExT• J BOS DISTRICT LOCATION CODE <br /> ( ) on n <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 <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 JoAQu1N <br /> COUNTY Ordinance Codes,Standards,STATE and DERAL la)#S. F <br /> e <br /> APnuQAw`r'.Ql"-mF� "•/ /O .rY flet 1 U�q1/ ' DATE: <br /> PROPERTY/BUSINESS OWNER Lr ERATOR/MANAGER ❑ OTHE ATHORyLE AGENT❑ <br /> IJAPPLICANT is not the BILLING PARTY proof of authorization to sign s required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to the or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS; <br /> •EB U 5 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: �� I PIE: I I„ <br /> Fee Amount: $ 1 C3 Lam= Amount Paid Payment Date a / 18, <br /> Payment Type G Invoice# Check# U S Received By: 7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />