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IF I IF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> IF <br /> SERVICE REQUEST <br /> ;Type of Business or Property . FACILITY ID # SERVICE REQUEST # <br /> RIF <br /> OWNER'/ OPERATO <br /> CHECK If BILLING ADDRESS <br /> FAcILITYNAME 17-, J O ( c <br /> i <br /> $ITE ADDRESS' 'lumber St a <br /> HOME Or MAILING ADDRESS ;(if Different from Site Address) <br /> Stroet Number Stroat Namo <br /> CITY STATt: ZIP <br /> PHONE #t EXT& APN # LAND USE APPLICATION # <br /> ( <br /> PHONE #z Exr. . . . BOS DISTRICT LOCATION CODE <br /> IF CQ�1'TRACTOR / SERVICE REQUESTOR <br /> REQURTOR CHECK if LLI G ADDRES " <br /> 71M6 yd / <br /> BUSINESS NAME PHONE # ExT. <br /> T' v/I/ Wkwoo P /1f i �J <br /> fl L C41% : M q3 N o �-9 �- <br /> Hp E or MAILIN ADDRESS O �j FAX # , <br /> 7 3 <br /> !TYyy� f..j TATE ZIP. C'f <br /> BILLING ACKNOWLEDGEMENT: I, .the undersignedproperty or business owner, operator or authorized agbnt of same, <br /> acknowledge that all Site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges . aSSOclated 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 with all SAN JOAQUIN <br /> CouNTY Ordinance Codes; StandardS� STATE and FEDERAL laws. . <br /> APPLICANT'S SIGNATURE: DATE : <br /> PROPERTY I BUSINESS OWNER [3OPERATOR I MANAGER ❑ . . OTHER AUTHORIZED AGENT <br /> IfAPPLicawr is not the BacrNs PpRrY. proof of authorization to sign is required Time <br /> AUTHORIZATION TO RELEASE INFORM,AT(ON: 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 , geotectmtcal data and/or environmentallsite assessment information <br /> to the SAN JOAQUIN Comm ENVIRONMENTAL HEALTH DEPARTMENT :a8 Soon as . lt is available and at the same time It IS .provided to me_ or <br /> my representative. <br /> 4 TYPE OF SERVICE REQUESTED) 2 '/ 14- f . PA <br /> COMMENTS: RECEIVED <br /> MAY U 3 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTteD. BY: : . - EMPLOYEE #: , ' E DATE: t+ <br /> ASSiGNED.TO: Li V [� EMPLOYEE #0 00 � � DATE:MINIM <br /> tc� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �l} <br /> Fee Amount: , _ -- -- ' Amount Paid , Payment Date t <br /> Payment Type Invoice # Check # i d -7 ti Received By: <br /> NO <br /> EHD 48.02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />