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aNi,Ipaniaaa}� i <br /> SAN OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' SERVICE REQUEST <br /> Type of 6uslness or Property FACILITY ID€I SERVICE REQI.I>`ST# <br /> /'1E A sp- (a <br /> I <br /> OWNER/OPERATOR <br /> S' f CHECK If BILLING ADDREA] S <br /> Si7(E�ADDREES�S <br /> NumberD1 —G--�•2 S G�e- �. - ro -` 3 3[] ,II <br /> HOME or MAIt1NGADDREn (lf Different from Site Address) 0 fly <br /> F i <br /> Sheet Nu m bei Street Name <br /> Crr" K S TATE Z1P <br /> PHDNE$t exT• AP111#: LAND USE APPLICATION# <br /> •O 0 - <br /> PHONE ffi2T• 1J BOS DISTRICT 1woCATION CODE <br /> CONTRACTOR t SERVYCE REQUESTOR <br /> RE(]UESTO <br /> CNECXifE1LLINCa.ADDRESSO <br /> 5-P Sri_ <br /> BUSIPtESS NAMEB6 CL <br /> HOME orMAlum ADDRESS Fix <br /> 4J I �4 73 <br /> CITY STATE Zip <br /> BILLING A f-WN WLEDGEAfE : ], the undersigned property or business owner, operator or authorized agent of same, <br />`--arknowledge-that-ail site'andfarpiaject'speeiEzc L 1RONlv'r-N VAL )=IEAT t DfP.axTNtENIT hoiuly dhargc3 aS�s-oeiated-vlitb-dlis giotecty" ] <br /> or activity-,4ill be billed to me or my business as identified on this fang- r <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 Ja9QvtN / <br /> COUNTY Ordinance Codes,Standards,STATE andl'EDER V,laws- <br /> � n <br /> A-PPLICANT'SSIGNATURE: r—D-*TE• <br /> Pxor�R'rY USWEss On-N>t IJ OPEvkroR I MANAGER iJ ,j f d' BER AvimowzED A(;E.NT© <br /> lfAPPLfCAxT is riot the B'LuxG PAR7:proof of authorization to sign is required Title! <br /> UT GRIZATION TO RELEASE INFORMATIO 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 enviromznentaUsite ass ent <br /> information to the SAN Jo.kQm COLN'lY ENVIROA'VI.N?AF.HFALm DEPART1viF_N"1`as soon as it is availab:c:and at the sam�ti i`s <br /> proi.nded Co me or my representative. C <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: M <br /> YAMINO <br /> mX <br /> rn <br /> ACCEPTED BY: EMPLBYEE#: DATE:' 71 { [ t <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> i 'l P117 <br /> Date Service Completed (if alreadly'completed): SVz CODE: 1 E: <br /> Fee Amount: NAmount Paid rx[70 Payment Date —11191 � <br /> Payment Type PAcheck•# Received <br /> Y���T i3 <br /> EHD 48-02-025 <br /> RECEIVED SR FORM(Golden Rod) <br /> REVISED 11117,12003 <br /> JUL 19 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Z-d HVE6WAb#1 DEPARTMENT esnoypeo�j uodo�j eV9:01 L G 61 Inf <br />