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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> REQUEST# <br /> 0 00 Z� (0 00?S i O <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> �2,�G� 1,�L 11��ti�L h� � � .,� ' f`/r✓ <br /> SITE ADDRESS EyzLG U IZ42 j_�Z/S <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHON 1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n <br /> CHECK If BILLING ADDRESS■�.. <br /> BUSINESS NAME <br /> 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , <br /> � C,, —` '&j DATE: G/_ c o <br /> %i <br /> � ZZC2 <br /> �-t� F <br /> PROPERTY/BUsINESS OWNER4J 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 <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: r V�C� v I nvi [,M <br /> COMMENTS: RECEIVE® <br /> JAN 0 9 2020 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: Y � �(�J EMPLOYEE#: HEALT MPARTMENT <br /> ASSIGNED TO: /ti QCl J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ;2) P i E: <br /> Fee Amount: L{ ., _ Amount Paid 4'4' <br /> If �- Payment Date i <br /> Payment Type Invoice# Check# Received By: L(= <br /> EHD 48-02-025 ✓ `+ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />