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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,.�( ,Si:iIL . R. Co 7 <br /> On f OPGRATOR I 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME A ( I-- <br /> ` IVtI ue- <br /> SITE ES y.L T �, i �/ u, S` jG � jv q- 2 <br /> IStreelN,umber Direction se Name CI Zi Cotle <br /> HOME or MAILING ADDRESS (If Different/from Site Address) <br /> Street Number Street Name <br /> CITY S�A E IP ,^ <br /> PHONE#t EXT. APN# o4 clot) LAND USE APPLICATION# V <br /> -2A ( 5S �� <br /> PHONE#2 EXT. BOS DisTRI�T LOCATION CODE <br /> ( ) rVV\\ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# II C. ExT. <br /> 2[l Z4 !O o� 7 <br /> HOME Ol�r MAI GADDR55 /^ fil�� (AX# ) <br /> CITY I l� _ /v'1/.Y I SAT zip r� 2 / Z <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 /> 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:'� Gt� rli DATE: S I <br /> PROPERTY I BUSINESS OWNER❑ OPE`RAA4 ANAGER 13 OTHER AUTHORIZED AGENT 13If APPLICANT is not the BILL,'N ARTY proof of authorization to sign is required Title <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: RECEIVED <br /> MAY 12 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTM <br /> ACCEPTED BY: ::an.V, EMPLOYEE#: DATE: <br /> ASSIGNED TO: e-lX EM PLOYEEM DATE: C5, <br /> Date Service Completed already completed): SERVICE CODE: PIE: 1�� <br /> Fee Amount: AmountPaidPayment Date <br /> Payment Type Invoice# Check# Received By aU,- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />