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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> OWNER It OPERATOR" f <br /> Nawsl.,.,d �- '!n CHECK if BILLING ADDRESS <br /> FACILITY NAME /1 - P0. )a C�12—rr�� <br /> SITE ADDRESS 49h' Po`U TI,L Avg ; --RT2N Sfoc.k 40-r? 95207- <br /> Street Number Dir¢ction Street Name CIN Zip Code <br /> HOME Or MAILING ADDRESS (ifDifferentfrom Site Address) <br /> �6 �Q Jr✓• cx �k;d ClY+ 1q-P Street Number Street Name <br /> CITY / C K (-r', STATE f_/4 ZIP 052-07-- <br /> PHONE#1 7 ^, Exr' APN# �J LAND USE APPLICATION# <br /> (I NAW45 6521 Ib <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) U ) <br /> CONTRACTOR"//SSERVICE REQUESTOR <br /> REQUESTOR � 1/ <br /> J / 2/S +� fvr +�Y �I �'JCY, <br /> CHECK if BILLING ADDRESS <br /> n PHONE# EXT' <br /> BUSINESS NAME C'aL,7dd Pa lacp- <br /> 1 ��{t,�,, �_/;{. —21 / ('2/ <br /> HOME or MAILING ADDRESS O 5-bTo�-fovud Gh APt.# 33 FAX# 0J <br /> CITY LJ..fr K4-pn STATE ZIP g zp2 <br /> v 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 /> 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: DATE: 6 / <br /> PROPERTY/BUSINESS OWNER M OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> TYPE OF SERVICE REQUESTED: — ;� `�-'lt 5 Lj i-n'+1 <br /> COMMENTS: <br /> MAR 14 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL - <br /> HEALTH DEPARTMENT. c <br /> ACCEPTED BY: .-V�G -- r�eS y EMPLOYEE#: DATE: "7 <br /> ASSIGNED TO: <br /> V'C' EMPLOYEE#: DATE: '37 <br /> Date Service Completed (if already completed): SERVICE CODE: 0& PIE:: 1 <br /> Fee Amount: Amount Paid (rj" Payment Date <br /> Payment Type f-) 6��. Invoice# Check# Received By: — c <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />