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SAN JOAQUIN�— ,UNTY ENVIRONMENTAL HEALTH D`_ ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S U \� <br /> OWNER/OPERATOR B <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS (� U�\C1l1 S� 195 <br /> z�o <br /> Street Number Direction treet Name Cit C0. Zi Code <br /> HOME OrMAIfINraADDRESS (If Different from Site Address) \ <br /> _ Street Number Street Name <br /> CITY STATE� ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2o ) S/,30 � g <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR xa,�,Z <br /> CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME / Gn/ �/f� r, / Ay/ PHONE# D EXT. <br /> HOME or MAILING ADDRESS ( FAX# <br /> _S 314Z�Iil Willl c ► <br /> CITY0C- A/-06v STATE ZIP S. 2-0 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STATE and FEDERAL laws. / <br /> OAPPLICANT'S SIGNATURE: /(��/�%(� �L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 1, 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. <br /> TYPE OF SERVICE REQUESTED: i;� d P P <br /> COMMENTS: <br /> CE jVE� <br /> NO � � 2020 <br /> SAN JOA <br /> H NVIR pNM�Co <br /> ACCEPTED BY: ` �1 EMPLOYEE#: DATE: � RT <br /> ASSIGNED TO: \� t/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: vt�\ PIE: <br /> Fee Amount: —� Amount PaidPayment Date <br /> Payment Type r�� ,!�i�;� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />