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i <br /> SAN JOAQ• COUNTY ENVIRONMENTAL HEALTH L,trARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C VIV�7 � q qZC��t�,q q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS 37 <br /> 1 Street Number I Direction �` �L�L\t Street Name Ci `l ` t Zin Code <br /> HOME Or MAILING ADDRESS (If Differen r/o/�tp Site Address) <br /> !J c V LL Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. r BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I S / /_I n I� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C R H t)12t Z S <br /> HOME or MAILING ADDRESS FAX# <br /> CITY n/1 STATE zip (-f S <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 arld that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE nd 1�91DRAL law ---- <br /> APPLICANT'S SIGNATURE: ^/ DATE: r 2-- <br /> PROPERTY <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER Ld 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 to me Or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: i S U RECI.IVED <br /> COMMENTS: pp^^ n p L j 12 2016 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEAI TH DEPARTMENT <br /> ACCEPTED BY: Lama Vawflc' 16holh <br /> EMPLOYEE#: DATE: 0 /Z W <br /> ASSIGNED TO: EMPLOYEE M DATE: 10 <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: ,�(7?LF P I E: 2)I I <br /> Fee Amount: 12j Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />