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SAN JOrk ,N COUNTY ENVIRONMENTAL HEAL', /EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />0, CA.) .1- i uk.c.t( <br />FACILITY ID # <br /> e,0 <br />SERVICE REQUEST # <br />DA b6 7S 617 I Nip I OPERATOR <br />Rboe,e .% VaCb \.4e (lAckt,vdz__ CHECK if BILLING ADDRESS <br />FACILITY NAMETa co r. L7 P- 2— <br />SITE Apfcc <br />Q 0 (,) Street Number -.) - — Direction eet Name <br />li./ ti <br />fa, tigirl Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Addres <br />—7 --) 6) 6 1-. Street Number Street Name <br />CITY STATE ZIP S\-ci ( el 7 3 2o <br />PHONE #1 EXT. <br />( 7 69 5 evy _sc( 5 eir APN # , itomo,)-o LAND USE APPLICATION # <br />PHONE #2 EXT. Ii BOS DISTRIC LOCA4N4ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR n 1 <br />1.4.-nel(46 , 1 1 et'y 1 cto 2- CHECK if BILLING ADDRESS <br />BUSINESS NAME • <br />1 a ( 0 pi,7 0 2 PHONE # <br />Vde ) S 7 y- 5-c( 5 <br />E)T <br />61 <br />HOME or MAILING ADDRESS <br />7 3 3 0 S o-V <br />FAX # <br />( ) <br />CITY c-)\-cJcklttL STATE 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: \2. (96 C 7\ '0 V \ <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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: Pboct_ \i/ Pilv Le. 1 1`- p-ec-J-rOlf ) iiii• r <br />COMMENTS: CEA/fr./14 <br />1Cel DEC 0 uuti5_e_ r) Li P1 thec 5 y 9 ) 5 9 :), sAN Jo, ? 2017 -Alt „-,QuIN ii,10. R04,44 couA, <br />AR j'Aic‘Air <br />ACCEPTED BY: .. p'EMPLOYEE #: DATE: 1 a... , 7 _ ) 7 <br />ASSIGNED TO: 4...tA, 0\ 0 V.\ EMPLOYEE #: DATE: ic , 7 . / 7 <br />Date Service Completedlif already completed): SERVICE CODE: 0 6., I P/E: /te e) <br />Fee Amount: 1S,D-6) Amount Paid, /L-",_? (,) )--. Payment Date <br />Payment Type Invoice # Check # Received By://7( / <br />PROPERTY! BUSINESS OWNEI4L. OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />DATE: 12 I <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)