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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 1 FACILITY ID# S(ERVICE/RcE�QUEST# <br /> 1� 0,&I l I � l�o rY I C.T'� K ) l/�� �r <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Jesse ��7-�o-V\ Manu aY � ✓� <br /> FACILITY NAME 1 1 O <br /> OWrY OWE 'Y1 / <br /> SITE GDDESS VJ md.Zh S� �l�o V� 85366 <br /> Street Number I DlrecHon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) C�{ +h &v e <br /> 1 2 S Street Number Street Name <br /> CITY STATE ZIP <br /> r-'\ &^ C C C' 5 L <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (7M 988- 7V) ) <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> O V1 L-0l E q vn k I I C Z.Yv1 <br /> CONThACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �„t ��, <br /> CHECK If BILLING AODRE55 <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <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 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, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> , .1 AWL ",'C.( �d+ ,� DATE: 2 -Z� I -7 <br /> PROPERTY/BUSINESS OWNER ys OPE T /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT ISI not the BILLING PARTY,Proof Of authorization t0 sign is required Titre <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 t0 me Or <br /> my representative. —JAAA-TYPE OF SERVICE REQUESTED: I�A,[AA- PAYMENT <br /> COMMENTS:J ci n OV OK RECEIVED <br /> FEB 2 8 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: "�'� �� f� d/ �/ b EMPLOYEE#: DATE: L', �'� <br /> ASSIGNED TO: j a ✓l/"� C/VL EMPLOYEE#: DATE: � 2L� <br /> Date Service Completed (if already completed): SERVICE CoOC S'�" (�Z . PIE: I `1 <br /> Fee Amount: t5-,G-0 I <br /> Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />