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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID # SERVICE REQUEST # <br /> 6a s Sti, R OU U ISM S2 00 I � � <br /> OWNER / OPERATOR <br /> \) <br /> � • CHECK If BILLING ADDRES <br /> FACILITY NAME I f e \�w./D N C J `�. <br /> SITE ADDRESS Zl � E- ,v� ,M � � t �j � c ��SCo eco <br /> Street Number Direction Street Name Cit Zi 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 /> ( ) 0°1 q 0 31D 12 <br /> PHONE #2 ExT. BOS DISTRICT LOCATI ODE <br /> ( ) 002 <br /> CO <br /> NTRACTOR / SERVICE REQUESTOR <br /> REQUESTO �— A \ CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> Con <br /> U 5T. <br /> T ( \` Coo P� # I ( 2 ! Q <br /> HOME Or MAILING ADDRESS I naj (� # <br /> CITY STATE ZIP I I <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 /> also certify that I haveprepar this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stan s, STATE and FTI RAL laws . <br /> APPLICANT' S SIGNATURE : 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 , 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 soona it is available and at the same time it is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Ca - a NWI <br /> Fm <br /> t - <br /> CIVT <br /> COMMENTS: <br /> I ft6v'ED <br /> DEC 0 6 2019 <br /> S�NI/lRpUlN COU <br /> HF-Al NMENT' NTy <br /> ACCEPTED BY : r f V & EMPLOYEE # : DATE : / <br /> ASSIGNED TO : r EMPLOYEE #: DATE : Aa loll <br /> q <br /> Date Service Completed (if already completed) : SERVICE CODE : PIE : 23OC� <br /> Fee Amount : !� Amount Paid D D Payment Date /�I/ <br /> Payment Type ( � Invoice # Check # ��y�J— Rece ved By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br /> I <br />