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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />cROO -1G -7 n, <br />OWNER / OPERATOR , <br />CHECK if _via !Janie% 4- ecti 1,(10 ce llo samb /41 /7 BILLING ADDRESS 0 <br />FAcusry NAME --I.- <br />/ a te 5 L GI ill C.A. I-Cki I ( 1 (LS 9Y1- c7,1 <br />SITE ADDRESS ,...2 y rv 0 0 <br />Street Number il-') Direction f101aitt' Way <br />street N2me 1 <br />S --0C-1)-(-0 0 <br />City <br />952G( <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) /5 '70 <br />Street Number D 2. • <br />I CC"' Ytreet Name <br />CITY <br />CkkA-0 Y1 A- O <br /> <br />STATE ZIP <br /> <br />Cig• 9520 3 <br />PHONE #1 Err. <br />(76,q ) 5-9 d/- 3 -7-s? <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(logs q3 — q 3 L-/I <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR.4 , <br />Ka t I a Dcwilel -ke_t kiedc c---. ...., a i 0 ,-s- Gyi. c , uxxv , CHECK if BILLING ADDRESS Eif <br />BUSINESS NAME <br />.—TCLI o Las ncco-u ‘ (c.,_s PHONE # <br />(zoo Sql/- <br />EXT. <br />7 S 6( • <br />/5 70 <br />HOME or MAILING ADDRESS FAX <br />----P 1 co-rct D 12- • <br /># <br />( ) <br />CITY <br />5A-OC kk.-1 0 NO STATE <br />Ot ZIP 9 Szo 3 <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 SIGNAT <br />PROPERTY / BUSINESS 0 EREI — OPERATOR/MANAGER I OTHER AUTHORIZED AGENT Ei <br />If APPLICANT is' not the BILLING PARTY proof of authorization to sign is required <br />091/5///fr <br />Title <br />(.7 DATE: <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: f OL,r1 va i c te co r s bt itAtion pAYMENT <br />COMMENTS: RECEIVED <br />sEp 14 2016 <br />SAN JOAQUIN COUNTY <br />ENVIHOMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Ail a- Mao rigk-h olTh EMPLOYEE #: DATE: (1 pi/fl u/ft) <br />ASSIGNED TO:Lj <br />na t-h11ynK EMPLOYEE #: DATE: q 7 fly / A, <br />Date Service Completed (if already completed): 1 SERVICE CODE: \;( Ci it I NE:) <br />Fee Amount: e , -.27 1 Amount Paid <br />L <br />Payment Date c.,11,4 I t is <br />Payment Type --( i. Invoice # Check # -7, c_._ I Received <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)