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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />---rOY'7 / f <br />,,, oi'le j,-. <br />FACILITY,ID # <br />i .))C, <br />SERVICE REQUEST # <br />5 R— 667%62) <br />OWNER! 7?(ERATOR <br />, e )///19 11° ,,,,k,--;,--1 CHECK if BILLING ADDRESS <br />FACILITY NAME___,-. <br />i 0 CP 5 &( <br />SITE ADDRESS <br />Street Number <br />f <br />Direction 7_16 <br />Street Name Citv <br />f "-S .5- <br />Zip Code <br />Fl,tE Or MAILING ADDRESS (If Different from Site Address) <br />/''ô 0 Y / V-2 Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />7 7 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />4'2°7 ) 773 -.1 <br />BOS DISTRICT <br />61a.,-7- <br />LOCATION CODE <br />ciq <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR,"1 <br />1 (e ye' II? 1( 0 kvl a 71 veg6f CHECK if BILLING ADDRESS <br />BUSINESS NAME- PHONE # EXT <br />Ho or MAILING ADDRESS <br />0 60 )( .)_Y, <br />FAX # <br />CITY L ,I/770/(4,‘,1 <br /> <br />STATE, ZIP <br />BILLING ACKNOWLEDGEMENT: 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 /> <br />DATE: <br />PROPERTY! BUSINESS OWNER 12( OPERATOR! MANAGER El OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <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 Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: F---0-3d ,.9c-1. t 1 CI ucic PAYMENT <br />COMMENTS: REChlVED <br />SEP 06 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />(ZI <br />EMPLOYEE #: DATE:CI, _ I g <br />ASSIGNED TO: i-h/L, t,j ri il EMPLOYEE #: DATE' .. 6, - ig <br />Date Service Completed (if already completed): SERVICE CODE: 52_ --1 P/E: <br />Fee Amount: 11 60 <br />LL, <br />Amount Paid <br />, <br />Payment Date i \ (.0 \ \,X <br />Payment Type \/,• Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />END 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />07/17/08