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SAN JOAQ0000UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST It <br /> ttcsT.a�R h Y I�UU1341 S S1'LDU�I '; - lv <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f r�-n N KS PLA t:r= <br /> SITE A <br /> DDRESS N ldE 7 M ,f, -rF� of S33( <br /> 2 Street Number Direction heet Name CI ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE 41 EXT- APN# LAND USE APPLICATION# <br /> 2'1; Lf rb Z - D O 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUES'TOR <br /> REQUESTOR L <br /> CHECK If BILLING ADDRESS O <br /> BUSINESS NAME PHONE# EXr. <br /> E R(ftrt t!�C 6& 2- • Y87y <br /> HOME Or MAILING ADDRESS FAX# <br /> 3 5 - S if 4 V6- ( ) <br /> CITY OCK N SMT ZIP 9 SLOS <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 /> 1 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`SSIGNATLIRE: } -Z!Ek' DATE: 7• 2- 1 - f fo <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR f MANAGER ❑ OTHER AUTHORIZED AGENT ^-'`C 1 FCC. <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required rule <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 t0 me Or <br /> my representative. j <br /> TYPE OF SERVICE REQUESTED: UTA Q C L�-' PAYMENII <br /> COMMENTS: <br /> JUL•z•1 2016 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> ^ q q <br /> HEALTH <br /> HrDEPARNT <br /> TME <br /> ACCEPTED BY: IN r�J l[/11 VI O EMPLOYEE#: /DATE: a- 1/ <br /> ASSIGNED TO: nI `lam LI GII J E+nPLOYEE#1 DATE: 7/,;,-1 to <br /> Date Service Completed (if already completed): SERmcE CODE: G 7 r} PIE: I[� <br /> Fee Amount: 'J) Amount Paid �� (� 'a Payment Date 7 I� <br /> Payment Type <br /> Invoice Check G3 Received y:7� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />