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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �/�H0FACILITY ID## SERVICE REEQ(UEST# 00 D�1' �GZ W�OnU�z OWNER/OPERATOR DFT Hr-)N DEF /_/'� // V �/ / / CHECK If BILLING ADDRESS FACILITY NAME ^„OM ,S " 1/0„P� IV Lh SITE ADDRESS 4, yq I/ /V, T/ro;') $f Street Number I Direction I Street Name city Zip Code HOME Dr MAILING ADDRESS (If Different from Site Address) 136* 1 Al s' A vF-- Street Number Street Name CITY eF STATE /]Yl ZIP _((Tm i 1,12 PHONE#1 EXT. APN# LAND USE APPLICATION# "I' ( Zoe b6� `7g`10 ak 2SO�P1 PHONE#2 EXT. BOS DIS RICT LOCATION ODE ( ) O4 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Q �y ()(,f MA? �JG(MCI'Il u h CHECK If BILLING ADDRESS BUSINESS NAME > PHONE# ^ EXT. DP.E "on' a-F5 kw)/v gc- b¢ X124 41 5 HOME or MAILING ADDRESS1✓6 AveFAX# / /// s1 l A ( )err CITY 944 y�,��s ea STATE r zip q,4 1,2,2 . BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and thatJhe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, STATE and FEDERAL APPLICANT'S SIGNATURE: �y DATE: Noy6 w 2a�& PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY Proof of authorization t0 sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED: ! �� COMMENTS: r® NOV 16 2018 �jwORQU/N COU I� NEALTIy CISPARN7A�TM ACCEPTED BY: 1", 0EMPLOYEE#: DATE,1� ASSIGNED TO:':::) SA dV� /wt EMPLOYEE#: DATE: Date Service Completed (ifalreadyco Ieted): SERVICE CODE: PIE; Fee Amoun�� Amount Paid )�2 Payment Date Payment Type Invoice# Check .kgs( 21 522, Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08 S