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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �� sf�tk Wkl" I-ce <br /> OWNER/OPERATOR <br /> U'-r f� CHECK if BILLING ADDRESS■- <br /> FACILITY NAME <br /> �.�S'CIVI t 611,s <br /> SITE ADDRESS 190 -6 W S r< L V1 5-/2! Z �� <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site A dress) I-�f 7 P <br /> Street Number treet Name <br /> CITY r �7 STATAF� 7�r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2;.11 ) Z- 10 - -+�-v IL <br /> PHONE#2N �t ( EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE EXT. <br /> 7 <br /> HOME or MAILING ADDRESS ` FAX# <br /> I � 3 Sc ) r/ ( ) <br /> CITY Lo STATE ! ZIP '?C2-L(0 <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 laws. <br /> APPLICANT'S SIGNATURE: 6,, Q--A• DATE: <br /> PROPERTY/BUSINESS OWNER d OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ f S-'A� a <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ti rle <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 Is provided to me or <br /> my representative. PAVMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> MAY 15 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: SEMPLOYEE#: DATE: ) <br /> r <br /> ASSIGNED TO: !) Q _ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): ' V` SERVICE CODE: P 1 E: I o9. <br /> OG <br /> Fee Amount: 00 Amount Paid l Payment Date <br /> Payment Type Invoice# �k# I L Received L / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />