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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Uo X39 S 0 w `7 <br /> OWNER/OPERATOR <br /> �, ' 1 ✓r�1 1,� S�t l� 4,� ' f�/�(i` CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Directior, Street Name I l"city`v,., l Zi Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) �� Vi <br /> Street Number Street Name <br /> CITY �/� <br /> 1 \ STATEn. ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2o,l 370) --] <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (Clnox��tD 1 1�"1 (,/� o CHECK if BILLING ADDRESS El <br /> BUSINESS NAME 1! l C Q S r A` k),�/ 4— �r ��I�ILf L-t C)� HAON: LI;31 EXT. <br /> HOME or MAILING ADDRES$/t ` 1n^ FAX# <br /> CITY c STATE <br /> t C Cl'` <br /> ZIP QlJ33-+ <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 /> 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. <br /> APPLICANT'S SIGNATURE: DATE: I a I I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tille <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 assess�p�+Qp�Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is�A�C��1A�, <br /> my representative. ``l1 rr II <br /> TYPE OF SERVICE REQUESTED: �k <br /> COMMENTS: WL. 2019 <br /> S ENVIAQUIN CO <br /> HEALTH pEp E MINT <br /> ACCEPTED BY: J I�`,r EMPLOYEE#: DATE: C� <br /> ASSIGNED TO: S `�;t /1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completedy. SERVICE CODE: -0„ I PIE: `u U?� <br /> Fee Amount: l 52 Amount Paid — Payment Date <br /> �b <br /> Payment Type `�o-IAej Invoice# Check# Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />