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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> REST.4L>v AtoT FP�06070Sgbo71458 1 <br /> OWNER/OPERATOR <br /> r CHECK If BILLING ADDRESS <br /> GOO lv <br /> FACILITY NAME MGDolJ,4t�D5 LATA p-o"!' q <br /> STIE ADDRESS 300 F- LO t7 i 5 F t LATA 7- <br /> Street Number I Direction Street Name CI ZI Cotle <br /> (HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I (- )U) ✓E Street Number Street Name <br /> CITY STATE ZIP <br /> LATvI Y LA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ,( > I l9g . ZIo -u'j <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> c\z - I/& I4SI. tSoo lI <br /> HOME or MAILING ADDRESS FAX It <br /> 59 t-V I (916 ) 4S . /(cc <br /> CITY hr STATE C ZIP 955)01 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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 th wo to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, Sr T an FEDE Ia ,t { <br /> APPLICANT'S SIGNATURE: � / DATE: ` -IsZ/,G <br /> PROPERTY I BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® 'FKbSEcr y119NALE.IC <br /> If APPLICANT 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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: I VI IG(�F- YMEW <br /> COMMENTS: RECEI <br /> APR052016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> JJr-ALTH DEPA'R`TMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: /.} ho <br /> ASSIGNED TO: (�� N�(,rl� EMPLOYEE#: DATE: I 4/5/1(0 <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: SL 522 PIE. I O ' <br /> Fee Amount: Amount Paid (Jr f ) Payment Date A, <br /> PaymenInvoice# f r� ( Check# _ ( ��1 (�•RRe�ceived By: <br /> W11� <br /> EHD 48-02-025 �W ` "✓��L wPy �ile� je.11 <br /> 1�rp' ,A/��� ^ SR FORM(Golden Rad) <br /> 07/17/08 d(/ � W\�, WV r r M,vt <br />