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SAN JOAQL,,p1 COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FP- 00 1 S r, b <br />SERVICE REQUEST # <br />cCiNc) 0 'Ai; 7 c -.- <br />OWNER / OPERATOR <br />, CHECK if <br />c) r( f 4 0 )-(W 0 <br />BILLING ADDRESS <br />FACILITY NAME e? ---• <br />Y D , J c le' i-C-e <br />SITE /ADDRESS <br />Street Number E. ection rep p / GI if Street Name <br />HOME or MAILING ADDRESS (If Different from itcrAddress) <br />Street Number Street Name <br />Cm( STATE ZIP <br />C <br />PHONE #.1 EXT. <br />( )4., 7) --yr) -; c.,-.1. 2, Li c.i. <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />—J71/74 )4r,1 )C_ G( 4:," <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Ti.") L,, ) _--) Li e C <br />PHONE # <br />(*f? ) 5 )3 Vci z/ ct <br />EXT. <br />HOME or MAILING ADDRESS <br />c)L/ Z-16:15-7/7/0/(b)- c - j ,--› <br />FAX # <br />( ) <br />CITYk--) STATE --1 )1\ 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: re )y.6 _,... 0)._(,) <br /> <br />DATE: / $ / ( <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <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 OF SERVICE REQUESTED: F-00C4 Ve,h, ( a ...f/r .c rail 1,0 RECEIVED <br />COMMENTS: <br />-41NI i 1 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />, <br />ACCEPTED BY: <br />l' (t, Maonciktokh EMPLOYEE #: DATE: 11 3 (/17 <br />ASSIGNED TO: )/r (t fru (,i 0 h , , EMPLOYEE #: DATE: ) f(/() <br />Date Service Completid (if already completed): SERVICE CODE: , PIE: <br />Fee Amount: 7,c ' Amount Paid 7 0., •cp b Payment Date 1 / --< i <br />Payment Type Invoice # Check # Received By: <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)