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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 001 2 JI <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS (� I� IS I <br /> Street Number Direction VU' I Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) 111 N 3 CihYDnit:l e �1✓e <br /> Stree_llNumher �/ Street Name <br /> CITY +-0r 1•••'/+0 n STATE ZIP c4q 91-6 O�_ <br /> PHONE#1 h• EM APN fI LAND USE APPLICATION# <br /> (20Cy —71 I <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> IJ <br /> 1'l ( r CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EK. <br /> SebPnn -S fin <br /> HOME Or MAILING ADDRESS FAX# <br /> I N 3 Ch a2Z2,Cle ailto ( ) <br /> CITY s STATE 609 ZIP 1? 20 <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 /> L-APPLICANT'SSIGNATURE: DATE: - Li)ne -? 7071 <br /> PROPERTY/Bususliss OWNER❑ OPERATOR/MANAIER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT 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 envir ITessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available a41Si[ttl2 set= Te it is <br /> provided to the or my representative. RECEI V C <br /> TYPE OF SERVICE REQUESTED: 2021 <br /> COMMENTS: <br /> SAN NVV RONIMENTALTM <br /> 1Ynl 1 I6/� ` HEALTH DEPARTMENT <br /> ACCEPTED BY: C , EMPLOYEE#: /) DATE: ta I 2 - <br /> ASSIGNED TO: ✓1 J EMPLOYEE#: 5 v DATE: ✓ <br /> Date Service Completed (if already completed): SERVICE CODE: 11E: n <br /> Fee Amount: g- (� Amount Paid `S Z _ Payment Date 7v <br /> Payment Typ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 P�o�NC11 1 <br /> V C� <br />