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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 1 <br /> 0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESSO <br /> FACILITY AME > O y/ ra L-) , C <br /> SITE ADgRE` j; 1 1 I D, (� I� SU �� J 1 vc 1 Vi t �/Q�U✓ <br /> tuber Direction ` i 6 Street Name Ci Zlo Code <br /> HOME Or MAILING ADESS (if Different from Site Address) C '" &Ic �C o <br /> / if 7�0 f Street Number C Street Name /) <br /> CITY STATE ZIP q 5o�c) 5 <br /> PHONE#1T APN# LAND USE APPLICATION# V <br /> C '3�' <br /> PHONE <br /> #2 ExT• BOS DISTRICT __7LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ei) JOZ6 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME /D✓ /( P # 1 ` �; Ext. <br /> HOME or MAILING ADDR S — FAX# <br /> G ' //,-? t5 O C ,5 c , ( ) <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 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 ith all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: d �c/�f` n toll- ,*(- DATE- D <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, 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 /> to 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. PAN � <br /> TYPE OF SERVICE REQUESTED: <br /> SEC Eat <br /> COMMENTS: <br /> OCT U d 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed ( ready completed): SERVICE CODE: 0 1 <br /> PIE: ' o <br /> Fee Amount: 15 Amount Paid Payment Date G I I ��( <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02- SR FORM(Golden Rod) <br /> 07/17/ <br />