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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businessor Property FACILITY ID# SERVICE REQUEST# <br /> �1T& y4J { . �rRc�� I Iaa� S2ob� /� S�I] <br /> OWNER/OPERATOR A h,t f ❑ <br /> > fail (� CHECK If BILLING ADDRESS <br /> FACILITY NAME �iJ I/'/ �Io L/J <br /> SITE ADDRESS /�\� IiG -ZOS z U <br /> Street Number Dlrectlon Street Name C ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PryO10t Q _� 3 E ' APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> I ) 1 11 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR //// rrS ,�.��(,t/CHECK If BILLINGA0DRE55Y 1. <br /> BUSINESS NAME T ov✓ Jwys / I P�NE) O ._ 7^- EZT. <br /> HOME or MAILING ADDRESS 11 d o MC H4h y 5 q(/e r_.�I _ Id <br /> Fax# S `l <br /> CITY S( e / /2/I/ <br /> STATE C 1 <br /> 4 ZIP v' 7-0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or protect 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. I <br /> APPLICANT'S SIGNATURE: DATE: V' 0- ` '] <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization to sign i5 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 ass ent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time il' < O me Or <br /> my representative. pp �� <br /> TYPE OF SERVICE REQUESTED: � �knL <br /> C� S Lta 1 +1 D D <br /> COMMENTS: 2017 <br /> Gv1a o F n� �pC <br /> nct ,�oE �v <br /> �A,h. <br /> 7r <br /> ACCEPTED BY: Q�y� EMPLOYEE M DATE: 1 - / <br /> ASSIGNEDTO: EMPLOYEE#: DATE: I — I i_ I' <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: I C);L <br /> Fee Amount: 1 GI Co 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 />