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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST lk(PAIV)p 6 <br />Type of Business or Property <br />�p 2 Q <br />FACILITY ID #Us <br />ERVICE REQU ST <br />FESTA V" N <br />NO <br />sqyJ 2018 <br />pa7TOIJ iY <br />PHONE If EXT. <br />-��1,-) <br />OWNER / OPERATOR <br />EMPLOYEE #: <br />R"k N C t S cc JA <br />V I e \ �•J L� d M CHECK if BILLING ADDRESS <br />l � i <br />FACILITY NAME <br />EL � R -v t— �- I <br />F I C A tJ �ST-�A(v R A <br />SITE b-7S7n%C <br />Q <br />U <br />CITY <br />2Al <br />�/V <br />�% Z <br />Street Number <br />Direction <br />Street Name <br />Amount Pai <br />i Code <br />HOME Or MAILING ADDRESS If Differ(en`t from <br />13 <br />Site Address) <br />y^ <br />AAS l A <br />`� <br />Street Number <br />Street Name <br />CITY7� G -r0 N <br />STATEZIP <br />_ 4 52 -OS <br />PHONE #1 Exr. <br />(�n7�) lllllJZ i V { <br />APN # <br />LAND USE APPLICATION # <br />[PHWE #2 EXT. <br />) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />S�(� G <br />�p 2 Q <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />NO <br />sqyJ 2018 <br />pa7TOIJ iY <br />PHONE If EXT. <br />HOME OrINDDR SS <br />EMPLOYEE #: <br />FAX # <br />1 <br />ASSIGNED TO: �V ( co <br />d <br />"C <br />( ) <br />CITY <br />Date Service Completed (1if already completed): <br />STATE ZIP L -� <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: _ DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTE3 �R-C it c t c—c: <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title I <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 Isprovided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />low <br />COMMENTS: <br />NO <br />sqyJ 2018 <br />pa7TOIJ iY <br />ACCEPTED BY: A fjf-; <br />,faza <br />EMPLOYEE #: <br />DATE: 1 <br />1 <br />1 <br />ASSIGNED TO: �V ( co <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (1if already completed): <br />SERVICE CODE: 5� 3 <br />PIE: , <br />Fee Amount: <br />Amount Pai <br />Payment Date / c7 <br />Payment Type <br />Invoice # <br />Check #O <br />Received By: ; <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />