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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 1�\ 00 9-'3 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS S // R+/. STUD✓ To ,-) <br /> ,, �L S <br /> UStreet Number I Direction Street Name Cityp Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> r Street Number Street Nam¢ <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> /7 1056 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR b <br /> O <br /> uko- <br /> CHECK If BILLING ADDRESS <br /> (4_177 t/'t 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 q��E�T <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this "" <br /> activity will be billed to me or my business as identified on this form. RECEIVED <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 and FEDERAL laws. / JUN 2 p 2019 <br /> APPLICANT'S SIGNATURE: DATE: SAN JOAoI IIN COUNTY <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT ElHF <br /> ENVIRONMENTAL <br /> AI-ru <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Th" DEPARTMENT <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. <br /> TYPE OF SERVICE REQUESTED: (� UJ <br /> COMMENTS: c7, <br /> lip <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ':�, 1 E: <br /> Fee Amount: Amount Paid — Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 [. p.' , SR FORM(Golden Rod) <br /> 07/17/08 <br /> 1�3 D coo p,7 <br />