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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � L Pert 0-0IE <br /> �2 <br /> OWN E /OPERAT ft <br /> 2 <br /> � e CHECK if BILLING ADDRESS <br /> c <br /> FACILITY NAME <br /> SITE A—R65IR <br /> Street Number Direction <br /> HOME o 1 G ADDR SS (If Different from Site d D <br /> pito <br /> Street Number (teat/do treat Name <br /> ClT STATE P <br /> � - s <br /> PNE#1 5 APN# LAND USE APPLICATION# <br /> M) �s -d L? i <br /> PHO E#Z ExT. BOS DISTRICT LOCATION CODE <br /> S9(� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> [2Zo\ n CHECK If BILLING ADDRESS <br /> BUSINESS NAME k O v[O PHONE# Exr' <br /> HOME or MAILING ADDR SS FAX <br /> CITY G _ STATE ZIP ` 20 2-- <br /> BILLING <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 /> I also certify that 1 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 aI EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:{ /'tL <br /> 1 0 -J� <br /> PROPERTY/BUSINESS OWNER❑ O /M I GER OTHER AUTHORIZED AGENT(LY tySA,�^{ <br /> IfAPPLICANT is not the BILLING PART}' proof of authorization to sign is required 9 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: iRE <br /> COMMENTS: <br /> OCT Z 8 2020 <br /> EQulV <br /> hMRC)jV COUNTY <br /> HFAf TH DE ART NT <br /> ACCEPTED BY: �i� �� EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: y P I E: <br /> r V <br /> Fee Amount: I Amount Paid «jf Payment Date <br /> Payment Type Invoice#(/1',Q�1/I ' n Check <br /> # Received By: <br /> REVISED 11117/2003 t,Vl I v-r I�D I `" SR FORM(Golden Rod) <br />