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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH DEORTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �R66�855Z1� <br /> OWNER PERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 2 <br /> SITE ADDRESS I el <br /> t� I GJ. O�,K•i U t1 «�� - - <br /> J Street Number Direction —he l 5tr¢et Name �\ CI <br /> Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) J Q •L) / <br /> ) _ Street Number S a""L I Q _treat Nam'e7— _ <br /> CITY _T STATE,.• ZIP <br /> PHONE#1 EV. APN# LAND USE APPLICATION# <br /> (q 1(J al - oaC13 <br /> PHONE 92 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R EST R <br /> �� _ r o CHECK If BILLING ADDRESS <br /> B SINES NAM& PHONE# Ezr. <br /> — O 3 <br /> HOME or MAIMG ADDRESS O FAx# <br /> V I ( ) <br /> CITY!' STATE ZIP 95()O <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 /> 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,STAr�and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C DATE: /0l " 1:�6 <br /> PROPERTY/BUSINESS OWNER❑ ATOR/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, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time It Is provided �y Of <br /> my representative. AV'fi ''N'r <br /> TYPE OF SERVICE REQUESTED; C I YED <br /> COMMENTS: DEC <br /> 2 2017 <br /> SANJOAQUI COUNTY <br /> ENVIRON VITAL <br /> HEALTH DEP TAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1,;?.a / <br /> ASSIGNED TO: ' 1 f�h EMPLOYEE#: DATE: /ca _d 1 <br /> 7 <br /> Date Service Completed tif already completed): SERVICE CODE: �� / PIE: / <br /> r <br /> Fee Amount: I DD Amount Pat b Payment Date <br /> Payment Type Invoice# Check# Received Ely: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />