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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C I-FE✓Rov GAj fTA-rra,v N641J S'�Do 7 221 <br /> OWNER/OPERATOR 1,/IIA y��� .�nra''LL((�� <br /> vwrG <br /> ) U fi `I <br /> PRE&T CYC N CHECK If BI LLING ADDRESS <br /> FACILITY NAME �-A kVTE6r4 GH-EVRvA/ <br /> SITE ADDREESSSa 5 I✓ fT 1`A&VT5CA 9S33-7 <br /> 1 1 I 0 Street Number I Dlrection Street Name CIW ZI Cade <br /> HOME Or MAULING ADDRESS (If Different from Site Address) 6, f(AG-Al R W-(L( T E-F,1 A{,C <br /> -2-92-3 Street Number Street Name <br /> CITY IM1 D I i 5L(A/ G4 STATE ZIP 6 <br /> PHONE#1 V E)T. APN# LAND USE APPLICATION# <br /> W ) 925 -785 -7-aoO ZZ�C - 6�Z'9-00Z <br /> PHONE#2' EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �EkR. CHECK If BILLING ADDRESS� <br /> BUSINESS NAME µ k M50CIA--T61 PHONE III ExT. <br /> (805)5-40 '.52-'f6 <br /> HOME Or MAILING ADDRESS FAX# <br /> 61 FAelF(C fTf 5RITC- 12-o ( ) <br /> CITY d.v L-(,(If a�r C STATE p3,fo( ZIP <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. <br /> APPLICANT'S SIGNATURE: DATE: (I Il S ,1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATT MANAGER ❑ OTHER AUTHORIZED AGENT Y^ti,11,CIP•Yt <br /> If APPLICANT is not the BILL1 PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 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 /> 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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: FV0 1Fvlt-n C+)15G* PAYMENT <br /> COMMENTS: RIFICEIVED <br /> NOV 15 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: iQ',tGtecrvrinZ L�ytVvGr� li EMPLOYEE III: DATE: 11(15J Lp <br /> Date Service Completed (if already completed): SERViCECODE: 76 C:51 PIE: 100 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />