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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST (do (7s3 -7(79 <br /> Type of Business of Property FACILITY ID# SERVICE REQUEST# <br /> 00-Z�s1-4 W <br /> OWNER/OPERATOR <br /> es U h CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 �treet <br /> Z Street Number Direction J Name f ' Cit eLa Zi "Cdde <br /> Hqg or MAILING ADDRESS (If Different from Site Address) <br /> l7 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# / <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> 4 L <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 S�E EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: j <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ / � <br /> If APPLICANTT is not the BILLING PARTY,proof of authorization to sign is required Tirl <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locat <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenta > ass��(ssmenI <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and toe same tmi <br /> provided to me or my representative.. / [ 1 I �E JOAQU/N <br /> AL <br /> TYPE OF SERVICE REQUESTED: Ve Y I r e /Z(O ll)► bT se �I� 1 Gi l l 1� , ENT <br /> COMMENTS: i4vk to Cy1((ll6t'e r4esufemerl15 6jr, �u � r <br /> I <br /> ZI r1 PS f X14 idPr�} � 6c ��Jr a{ ����. SPP 6tT 7' CPSGI-✓ J rI il�e+44� <br /> SAN J� 2021 <br /> M ENVjRONME OUNN <br /> �lTH p l NTAC <br /> ACCEPTED BY: I� .C� EMPLOYEE#: DATE: <br /> ASSIGNED TO: S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Dec- J P/E: Jd <br /> Fee Amount: I Sa Amount Paid 1 Payment Date 1114--2-1 2 <br /> Payment Type Invoice# VTaR# Received By: <br /> 353 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />