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o bo ei SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property L._ ; 6W-0 K ,c3 Ai r11K -- '-- FACILITY ID # 0.1.61.1)4 121 1) \ , . SERVICE REQUEST # OWNER / OPERATOR CHECK if BILLING ADDRESS FACILITY NAME Do W,Al TV L. e: 1 / o A )5 mil Kt-t- I'Cl- SITE ADDRESS 19, 10 1 Street Number Direction N 34 c-Rom - E A/T-0 St- Street Name Lop, CA City 95 ck,) u, Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 41 M 1-.-- Street Number Street Name CITY STATE ZIP PHONE #1 34,(4 6 9, qg EXT. (..261 ) A P N# OLA 5 1/ ki2 01) LAND USE APPLICATION # PHONE #2 Exr. BOS DISTRICT I LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR pti 5 1--t ,4L IS )-it.4 I-4 D4 (___ CHECK if BILLING ADDRESS BUSINESS NAME gt//0/1 1... ,1:----i) 41 /0' t I kl/ r\ 1 7- /2 (11.57- PHONE # I-1 77 EXT. HOME or MAILING ADDRESS I i-i 4 6 SA L F 6 el I? L. )1 FAx# ( ) CITY L 131 - 11 /'C 7 , A STATE C A zip c-y 5 3:3 v BILLING ACKNOWLEDGEMENT: I the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, ST ATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 0 — JO - c) PROPERTY / BUSINESS OWNER' OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required C g Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aqui at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: tooa C, ..,i„, , iT t Ce/ VEL5 COMMENTS: cilmy, 0 c 0\0\i \ k.o.ivA \ 4 1 , A PR 13 2020 i SAN Jo, ,... L, Aitlii:i1,Y,./N COONI-v ri EALTH DepirI ENTAL ' r AR TmeNT - ACCEPTED BY: \I OA Daeyt -D EMPLOYEE #: DATE: Li --- 3 2_0 ASSIGNED TO: 5\AAV, opvvulgel--ei EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P1 E: 1.p 02_ Fee Amount: _ Amount Pai0/5:z z5z) Payment Date z71-3/2_D Payment Type 11, Invoice # Check # / 723e- Received By: de SR FORM (Golden Rod) END 48-02-025 REVISED 11/17/2003