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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT /0A 0 5 qq67:2_, <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5fObtOg7 <br />OWNER / OPERATOR <br />ft\ (\.c, c•-___ C., _ CHECK if BILLING ADDRESS <br />...... <br />A <br />ACILITIN)LAME, le \ 0.13 s cc_ C ocz wry- 0 ID ,s, c \S <br />- street Number Direction 530 8 c\-(--‘ c .1\ v -c • Street Name 5----occi-cri, • <br />itv <br />os,,,. <br />Zipteode <br />HOME or Or MAILING ADDRESS (If piffeyent from ...,ite Addr \ss <br />I i C U\ 3 v CM if-t`A-k 0 - Street Number Street Name <br />Crry 1 <br />`--kc <br />STATE ZIP Cis 7C3 C <br />4,, TO (.- b•cN <br />PHONE #1 <br />e -6 1 9se <br />Ext. <br />7 7 8)- Z . <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />S' 1q;-1/4- CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />VCAr -6t ( • <br />PHQNE #9 <br />( / c 6 a ( -cis() <br />2- EXT. <br />HOME or MAILING ADDRESS ... 4 1 co \ SCi V CCIA%T6V (‘‘ N (S. ( <br />FAX # <br />( ) <br />CITY 34-0C-tk-1.) <br />STATE (' C i ZIP Ci s zic ( <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, S1JATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:7. DATE: / • <br />OTHER AUTHORIZED AGENT 0 PROPERTY! BUSINESS OWNER IR OPERATOR! MANAGER 0 <br /> <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required 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 saiskiiiit ovided to me or <br />my representative. ENT <br />TYPE OF SERVICE REQUESTED: C,00S int-la-1101) RECEIVED <br />COMMENTS: JUL 03 2019 <br />1 •6t.22-6k rat b '1'6\ *al v) LI- 0 0 mci.; ( , coin SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: a ra EMPLOYEE #: oig30 DATE: 7 3 19 <br />ASSIGNED TO: air-11 EMPLOYEE #: DATE: 7 3 19 <br />Date Service Completed (if already completed): SERVICE CODE: , i P : <br />Fee Amount: 5 00 Amount Paid Payment Date / <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)