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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � �'? c)(-)-'?�"t27�>q <br /> OWNER/OPERATOR <br /> C' 1i V, ��` _ �1Gt 1 — CHECK If BILLING ADDRESS <br /> FACILITY NAME it�J (�1 e <br /> SITEADDRESS C 6162CW <br /> Street Number Direction T ►' Street Name t Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (hy'1) ga� -- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R:EQUESTOR F-0vi <br /> /_eS, C� �L <br /> �-'�j �V V lC1 �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHON # EXT. <br /> HOME Or MAILING ADDRESSFAX# <br /> 1:30?1 <br /> �! �9Y� <br /> J <br /> CITY/ �j STATE ZIP Ql jZf�'J <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 /> 1 also certify that I have prepared this applicati and t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE `nd FE AL laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /f 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 <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: ' �'tCk C'V V2 D <br /> COMMENTS: fid(CO �� UCk- Rf�IA(, //� <br /> ,.`- OYC/Y >vL OCT 0 7 2019 <br /> EJOAQUIN COUN <br /> NV RONMENTALTM <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ,�I`����\J EMPLOYEE#: DATE: 10-1-161 <br /> ASSIGNED TO: 1_ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ?, P E: l O <br /> Fee Amount: LJ C0 Amount Paid Payment Date C � <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />