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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />DEC 02 2019 <br />SMVIRONV COUA/Iy <br />H <br />062RT NT <br />SERVICE REQUEST # <br />HOME 06MJJL,1NG A DRESS 3 <br />ox 02�� <br />EMPLOYEE #: <br />A 000 2-7 3-I <br />IFOWNER/ <br />S� 00.91 L1I 9-0 <br />OPERATOR <br />v <br />0 <br />A n ��/� lk <br />� L�HECK If BILLING ADDRESS E] <br />FACILITY NAME <br />Amount PaidI�a— <br />I <br />�x <br />C,rl <br />� <br />Payment Type <br />SITE ADDRESS 5OU0 <br />oes-`- <br />I,'t-j <br />SWT -A <br />°l SZ�O <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi Cotle <br />HOME Or MAILING DDRESS (If Different from Site Address) <br />(v1•�� <br />Street Number <br />Street Name <br />CITY <br />$ <br />ZIP <br />P 0 1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR & t - I V `(� Ie <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEPH <br />DEC 02 2019 <br />SMVIRONV COUA/Iy <br />H <br />062RT NT <br />ExT. <br />_ <br />HOME 06MJJL,1NG A DRESS 3 <br />ox 02�� <br />EMPLOYEE #: <br />FAX# <br />( ) <br />CITY <br />STATE O ZIP a <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE a9d DERAIL laws. / <br />APPLICANT'S SIGNATURE: _ DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGE OTHER AUTHORIZED AGENT <br />I,fAPPLICANT is not the BILLING PARTY proof of authorization to Sign is required t 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 me or my representative. PAWs.p <br />TYPE OF SERVICE REQUESTED: - b t% -W <br />REc <br />COMMENTS: <br />DEC 02 2019 <br />SMVIRONV COUA/Iy <br />H <br />062RT NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: Y I <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already c mpleted): <br />SERVICE CODE: Ow <br />V! <br />PIE: 1Q02 i <br />FeeAmount:*C5 D\) <br />Amount PaidI�a— <br />I <br />Payment Date <br />2– <br />Payment Type <br />Invoice # 1 <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />