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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />-FP\ ON:21(7----C7 <br />SERVICE REQUEST # <br />--'71C 0 Owi.07- <br />OWNER / OPERATOR <br />CHECK if <br />L `:-) VAWAOAD A \\DAU-- ..1-1 <br />BILLING ADDRESS <br />FACILITY NAME Cc1".-1, t \ Ore `.-ii-ot -W 1.--1-3 Lil svei L\ Scrrrt-\ <br />SITE ADDRESS <br />Street Number Direction (\-k--\') k-- - Sr VC 5Street Name <br />Nlcae_s-ko <br />City <br />cts3sy <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />C)- C (3(... >S 5' .3\1 Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 2-06i) E;A7---G \ c€, <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR • <br />,AltalAt 1 V1 •j Al at 1`42 1-? CHECK if BILLING ADDRESg <br />BUSINESS NAME <br />'f- iV- L-173' I —1 S Cl <br />PcM EXT ,s 1 2 ..,,,,,,„ i sly.) <br />HOME Or MAILING ADDRESS 0 -_il Fax # <br />( ) <br />CITY <br />V4e9A.12-A-6 STATE Ca ZIP el cs-2Z 7 <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 Of <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. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER Ei OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: - ----Wbtk (ANCSIA,M11/ <br />rift-11-tvi--rii-t- <br />RECF IVF D <br />COMMENTS: <br />FEB 28 2019 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />DATE: /212g 1(9 ACCEPTED BY: Nsi . V\tr\M) Ylt,3 EMPLOYEE #: <br />ASSIGNED TO: CD , (.411/1t+ \11 0 1 EMPLOYEE #: DATE:./2_ 2 <br />Date Service Completed (if already completed): SERVICE CODE: <br />— <br />0.40 PIE: , 6 z- <br />Fee Amount: elikk• M2 — Amount Paid 7 c i Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: 2 -2 -2-0 ci <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)