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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Lc,,JY MCyC"Z_ <br /> OWNER/OPERATOR <br /> Lo'vY, `Z, I DS C /� 1 G �� Q <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> �` t�'1 <br /> SITE ADDRESS <br /> S c c'���c� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r6117 <br /> `/' �Y ; \ 6117'1 Street Number " `� Street Name <br /> CITY JFC C �O STATE y\ ZIP 'C1 >C v� <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# " v� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR O v .1_ J _ka,n U CHECK If BILLING ADDRESS <br /> BUSINESS NAME lJ 11,�or ,C` P X <br /> �� �,��-� Lk r✓ D ,� -L-(�,i 41 <br /> HOME or MAILING ADDRESS / FAX# <br /> 6 ( ) <br /> CITY STATE ZIP q5j C55 <br /> BILLING ACKNOWLEDGEME T: 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: (1 <br /> TOCjL: � . `(� �_ DATE: (�—1 — )Q — <br /> PROPERTY <br /> 1Cay — <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tule <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 I Wfb�}�O711e Or <br /> my representative. /�I 10r mmCryry 11 <br /> TYPE OF SERVICE REQUESTED: 0 C�4�1 rj� (/`,CS a I <br /> COMMENTS: i : 'I 0 y 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Y l� EMPLOYEE#: DATE: + —I <br /> ASSIGNED TO: U1 �/� EMPLOYEE#: DATE: 6 —1 <br /> Date Service Completed (if already completed): SERVICE CODE: 0 n PIE: I <br /> Fee Amount: 92 Amount Paid C Payment Date In,-,7 �Q <br /> Payment Type Invoice# Check# Received By:U <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />