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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property N/2i,( 5-rg) A L_ FACILITY ID # SERVICE REQUEST ,gg ooeiv-77- # OWNER! OPERATOR , CHECK if gDeEILT5 0 /45 REAP illlk BILLING ADDRESS 0 -- FACILITY NAME I SITE ADDRESS / 050 0 Street Number k.0,13/2-1-50/•1 /1?---ADV MX 5 Direction 7-14 z..4A/ /2 04 1) Street Name ,--724-Neg eArkif City -..z 95 3 / Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) t,c ,0 Street Number 5 . o 4071 d2,4 i AI 5-724E7 Street Name Cm' STATE ZIP C e KO AI A elf 9.7Z eaz PHONE #1 EXT. (g° ) 74' 0 —42- C3 APN # f3,27°—/f LAND USE APPLICATION # PA -I? oocz PHONE #2 #2 EXT. (624* / ) 733-039S BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dont c-f -i.5-NEyI Pe CHECK if BILLING ADDRESS BUSINESS NAME , , CH .5.t\t ey C-0/VSUL77AM7 PHONE # i Err, HOME or MAILING ADDRESS 37 et-4- FAX # ( ) CrrY ....-- 1 1.-r P-L-0 C_K_ STATE (A ZIP ---1 (IS 3i3 I 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 certitY that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, "E and FE" AI., laws. D1TE: /02130/9 APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER,: OPERATOR/ MANAGER El 17,7 aniER ArruoaizEo AGENT L.'J PPLKA NT is not the BILLING PARTY proof of authorization to 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 anchor environmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED: 5- O It ,-‹* I i 17-4 A f 1-- i 7 —1 / 41 / rgArE 1-0ADIttl 5-71, PIES ,P,5.1//E1/1/ COMMENTS: , Act /yr eo DEc 3 n SAN , u 2019 wOAQ ACCEPTED BY: 07---'20 EMPLOYEE #: i4%. itt2tR p ASSIGNED TO: EMPLOYEE #: --1 DATE: An NEN r Date Service Completed (if already completed): SERVICE CODE: .5- 2_3 I P1 E: Z60 ? Fee Amount: g mdc) Amount Paid (e a-- Payment Date Payment Type Invoice # Check # :Vo n° Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003