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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/OPERATOR <br /> Qtit1(t — a�P G�wra CHECK If BILLINGADDRESSE] <br /> FACILITY NAME a l?C Q/ M Q <br /> SITE ADDRESS L,J�� nn< R4 <br /> C— <br /> Qe� <br /> G � ` Street Number Direction Street Name cityZI Cotle <br /> HnMc nr MAII ING ADDRESS (If Different from Site Address) <br /> 3`�O(o CeclaadalLy?T:e <br /> hU F�TLl�'t Street Number tr¢e[Nama <br /> CITE-Ja STATE CZIP <br /> �'�s e � <br /> PHONE 1 E". LAND?ISh APPLICATIO 2O J C3� <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ey I ' \/O`, � CHECK If BILLING ADDRESS <br /> BUSINE85 NAME- q J" I' {.9C.T} PHONE# EXT. <br /> I XZ " 1-e— F L�c� Ru -e i" t �CJr �o p� <br /> HOMEor MAD.INGAD RES FAX# <br /> -3 3l L (." /I p I > <br /> CITY -)Io IQ 4 c) q STATE ' ZIP G'5-S S/ <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 /> 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. ?-11012011 APPLICANT'S SIGNATURE: 6 Ca( DATE: Z 1�� 20l//1 'I <br /> PROPERTY I BUSINESS OWNER❑ OPERA R/MANAGER ❑ OTHER AUTHORIZED AGENT t}I ti�i o n t7-e 4 <br /> If APPLICANT is not the BILLING AR ry proof of authorization to sign is required Title 11 <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 /> 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. <br /> TYPE OF SERVICE REQUESTED: -l0� J <br /> COMMENTS: ENT <br /> �� /�U RECEIVED <br /> �J,k/, <br /> FEB 10 2017 <br /> SAN JOAQUIN COUNTv <br /> ACCEPTED BY: EMPLOYEE#: H 'D <br /> E ' <br /> ASSIGNED TO: EMPLOYEE#: Cys DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:2 0 <br /> Fee Amount: Amount Paid OILW D E jq.. ' Payment Date Z U l�] <br /> Payment Type C�Ie&- Invoice# Check# g y-y5 Rece <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />