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a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> /q b b 3 Street Number Direction F� t NameK C Ci /ZI CodeO v <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> I Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> e /f�e �'-� /J/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME ,`� (� C PHONE# EXT. <br /> d <br /> 61-4 6131 <br /> HOME Or MAILING ADDRESS // � � �^/DO ✓�� n � FAX# ) <br /> CITY <br /> J � '• STATE f/ 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 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, Standar S, STAT nd FEDERA ?/ <br /> APPLICANT'S SIGNATURE:- DATE: <br /> PROPERTY I BUSINESS OWNER 1:1 OPEaTOR/MANAGER ❑ OTHER AUTHORIZED AGENT El61/y7 Q L-I-e2 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirle <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 Soon as It IS available and at the Same time it Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CCZ G � S`�- 767 ra SCS�� lti -�Te <br /> karl&r (.s- <br /> ACCEPTED BY: EMPLOYEE#: DATE: s^ <br /> ASSIGNED TO: EMPLOYEE#: DATE: G <br /> Date Service Completed (if already completed): SERVICE CODE: �7 PIE-11"N <br /> Fee Amount: `� Amount Paid Payment Date <br /> t 31 PAYMENT <br /> Payment Type Invoice# Check# TlReceivedBy1WEIVED <br /> 1 3 1 2019 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />