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SAN JOAJI COUNTY ENVIRONMENTAL HEALTHREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FADoIS(Dl IISK9- 00 _T7C�_ �/ <br /> OWNER/OPERATOR C)Lf,) q()W A l ri tl /� r� Kt T CHECK If BILLING ADDRES� <br /> FACILITY NAME Or Vl �n'+ llA\ K '�VP't'1<y-�'Ij <br /> SITE�(A]/DDDR�R�ESS (/V IN l V S P C ���'C�O� �� <br /> �l_ J Street Number Direction > Street Name CI ZI Code <br /> HOME or <br /> M <br /> A <br /> ILING ADDRESS (If Difffeerrent fro lmr�S'it caress C <br /> 3�CJ p�V Ll C SUeetNumber Street Name n' J /�� <br /> ClT1(F-f e /` �V t AF- zIP q p62. <br /> PHONE#'I#�t/` rU' En' APN# LAND USE APPLICATION# <br /> PHONE#2 FXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IG pt Nw � � ' 1� t D y/�� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �'(1 f}� t r,`u A t�A M 17 PHONE#qr, <br /> HOME orMAILING ADDRESS <br /> //(�q 'tVc7-� ��1 C FAx <br /> lb l <br /> CITY f`_ {��`l 7 STATE cfl\ ZIP 2 <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,STAT and FEDERAL laws. tc� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MA(AGER 13 OTHER AUTHORIZED AGENT IJIf APPLICANT IS not the BILLING PARTY roof of authorization to sign is required Title <br /> AUTHORIZATION TO REL SE 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 /> 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. ry <br /> TYPE OF SERVICE REQUESTED: (� �(/ (kl 161..1 /(JY'„ f <br /> COMMENTS: ecEFI VED <br /> 'A" z 3 2017 <br /> SAN JOAQUIN <br /> HSA <br /> ENVIRONME OUNTi, <br /> ACCEPTED BY: EMPLOYEE#:DpEi DATE: j <br /> ASSIGNED TO: I N1 EMPLOYEE#: Iq DATE: <br /> Date ServiceCOmpleted (if already completed): SERVICE CODE: PIE: l b <br /> Fee Amount: 1 Amount Paid ' 3q Payment Date 3 23 1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />