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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bcPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR <br />(11. \n C. 0 S '\p CHECK if BILLING ADDRESS <br />FACILITY NAME e., i <br />NA.° C <br />SITE ADDRESS c Acculenk.6, <br />L.)2,(:) S .‘-- Street Number Direction <br />5 sc\c(tmo\ v„ a k._ <br />. ' Street Name <br />1c)6, <br />City <br />RY3114 0 <br />Zip Code <br />FME or AIt_ING ADDRESS (If Different from Site Address) 6, <br />\-/GV) Street Number Street Name <br />CITY (--, STATE c x ZIP C\ 5--/A. 0 <br />PHONE #1 <br />(q\ CO - +6 ' °3b5 <br />EXT. APN # k‹.--- <br />0 LI-53 zo 0 LAND USE APPLICATION # <br />PHONE 42 <br />( ) <br />EXT. BOS DISTRICT j <br />6 O L <br />LOCATION CODE <br />0 2— <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR n <br />UNNi \ V \(- \C 0 %'()C. CHECK if BILLING ADDRESS <br />BUSINESS NAME ET\ Me/s-1/4:),11, V3 e j \.....c.\ \O csti PHONE # <br />P1t,) --/1.6-Cl3Y-5 <br />EXT. <br />HVE or ),I;r ADDRESS\,Sci C-\- <br /> c )c. qi.bG ....1....... FAX # <br />( ) <br />Cm( <br />&CA \-. <br />STATE C,& Zip (.v.; G .3-2._ <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 lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar STA and FEDERAL laws. <br />r--s DATE: <br />PROPERTY! BUSINESS OWNER EA 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 />rAllIriGliNir <br />TYPE OF SERVICE REQUESTED: \ :-Z)f)( \Lpjai.a., S70€ J-70,1 RECEIVED <br />COMMENTS: <br />4 Z ((5! MAY 1 5 2018 <br />SAN JOAQUIN COUNTY_ <br />ENVIRONMENTAL <br />HEALTH DEPARTMENt <br />ACCEPTED BY: Cl.d ,--,-, t vi <br />EMPLOYEE #: DATE:51_ cp... r..../ g <br />ASSIGNED TO: Nr_tx h rki L EMPLOYEE #: DATE: 5,cic -fs,, <br />Date Service Completed (if a ready completed): SERVICE CODE: 0 to i P/E: <br />Fee Amount: 1 -•-z ...."-- Amount Paid Payment Date c-- . (9 5- , / V <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)