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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type, Business or Property IFACILITY ID# SERVICE REQUEST# <br /> M-n 3 qi? <br /> OWNER/OPERATOR �(_ _ <br /> /i'')/I pIN iQ N� !"nlCHECK If BILLING AD0RES5� <br /> FACILITY NAME / _ /( V /G <br /> ZISr2SDS1 rhI"S 5 FS /( <br /> Street Number Direction Street Name CI Zi Code <br /> HOME 0r M 313 AD��SS (I/Differept fro Site Address) <br /> e wUO (f� Street Number Street Name <br /> CITYUC // N STATE � ZIP CJ�2 G� <br /> PHONE#1 K Exr' APN# LAND USE APPLICATION# ` <br /> (70q) <br /> PHONE#2 ExT• BOS DIRI T LOCATION CODE <br /> (219`1) �� 7S(�( r 11 ODD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> j' CHECK If BILLING ADDRESS E] <br /> / PHONE ExT. <br /> BUSINESS NAME lo/ e UPb�GI S # 7S. 2- V,71 <br /> HOME Or MAILING ADDRESS X� 2 /�w / /I 9,r2 6 FA%# <br /> X ea Gf /�v ( )^ <br /> CITY 5'4 <br /> ' C� 00 STATE qy- ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> also certify that i have prepared this applicatigFKprid that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE a DE L I S. <br /> APPLICANT'S SIGNATURE: / DATE: —I�P� Ij <br /> PROPERTY/BUSINESS OWNER�ff— OPERATOR/MANAGE ❑ OTH ER 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, 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 t0 me Or <br /> my representative. _ <br /> TYPE OF SERVICE REQUESTED: Mt <br /> COMMENTS: RECEIVED <br /> JUL 16 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTEDBY: , �( � EMPLOYEE#: HEALTHIETE^rrN,,II���'I_1t _� <br /> ASSIGNED TO: S . VI/tA EMPLOYEE DATE: I �-CLvI <br /> Date Service Completed (if already completed):' SERVICE CODE: I PIE: <br /> Fee Amount: 1(5z— Amount Paid I S �„ Payment Date <br /> Payment Type �� c� Invoice# Check# Received By:7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />