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SAN JOAQWN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7 Lc <br /> OWNER/OPE TOR <br /> CHECK If BILLING ADDRESS <br /> C FACILITY NAME <br /> SITE ADDRESS <br /> —Los r> � 5 l� (�rJ� L'V CrlrC fL M L4j� Lt 57 <br /> Street Number Direction Street Name c1ty Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S --/4- 1/ ' . u"ACe-7_ A,* Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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, Standar ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUf6E-: DAT <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG T ❑ <br /> ItAPPL/CANT IS not the BILLING PARTY (hoof 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 t0 me or <br /> my representative. _ PAYMENT <br /> TYPE OF SERVICE REQUESTED: p ' �� rti c`— RECEIVED <br /> COMMENTS: C) FEB 2 3 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: f—����. EMPLOYEE#: DATE: <br /> ASSIGNED TO: lT EMPLOYEE#: DATE: C ll <br /> Date Service Completed (if already completed): SERVICE CODE: -L-7 6 P/E: Lb,o z <br /> Fee Amount: L "" Amount Paid i ' �� Payment Date �S <br /> Payment Type Invoice# Check# ()3 2S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />