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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> (FACILITY <br /> ype of Business or Property FACILITY ID# SERVICER UEST# <br /> OWNER/ IjERATOR <br /> CHECK if BILLING ADDRESS <br /> NAMEI 11 <br /> SITE ADDRESS ` CA- <br /> Street Number ire t,.n Street Name city Zii3 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 o-LtL li-OC3 lf�j C Street Number Street Name <br /> + <br /> CI STA-�]�v, C.�4,� 0'z�'2 ( L <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> Q 6T2 _ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ` ( ) <br /> 71 <br /> REQUESTOR CONTRACTOR / SERVICE REQUESTOR <br /> v' <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 <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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is no 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 <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. M. <br /> (� <br /> TYPE OF SERVICE REQUESTED: H it) rl- 000,H.ECEIVED <br /> COMMENTS: n t , <br /> I� SAN 17 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: Gjc�( Irv-0 <br /> ( EMPLOYEE#: DATE: <br /> ASSIGNED TO: �r'Ck EMPLOYEE#: DATE: lSv <br /> Date Service Completed (if already completed): SERVICE COD!, �?3 PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />