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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # rd, o 6 ).,9.9 <br />SERVICE REQUEST # <br />5 g_ 007 7i. <br />OWNER / OPERATOR <br />Lui 4:.scv-rtirQ. .0 cin c)0.--- CHECK if BILLING ADDRESS <br />FACILITY NAME La_ <br />nn CriOCK-Cn An&--- <br />SITE ADDRESS <br />"_- •Ck- -- Street Number Direction <br />5tigt11,0U, irk) <br />Street Name City CI S cio Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I--2-qq-:5 4 Street Number fl !4t-t) <br />Street Name <br />CITY Locb STATE ZIP cl 524D <br />PHONE #1 EXT. <br />(20 8 10 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />00 <br />LOCATION CODE <br />0 `2--- <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Lay) P.a_to u---ez_. 0 chat CHECK if BILLING ADDRESS ri <br />BUSINESS NAME <br />1 Ck M I CIPLO (k. C,Ctfi Cf <br />PHONE # <br />( 20) Fs1 0 Ce Li(b- <br />EXT. <br />HOME or MAILING ADDRESS <br />I 2— Lid -7D A, 1-44)14 2scis. <br />FAX # <br />( ) <br />CITY ir J._ oiA STATE Ce4 ZIP 45 2-46 <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: DATE: <br /> <br />PROPERTY! BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 same time it is provided to me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: ....„,-001. NI Ch i CIP 1 n 5p i <br />1°Pa Iiilltril I <br />RECEIVED COMMENTS: <br />P f2'• 6 1 (c) 2- -2— <br />id e Go c.,Ice45e, p ictic_ * 14 ,9 / 3Z / FEB 0 9 2018 <br />SAN JOAQUIN COUNT <br />ENVIRONMENTAL <br />HEALTH DEPARTMEN <br />ACCEPTED BY:5_447A EMPLOYEE #: DATE: 2_ - 9 • 1 cg <br />ASSIGNED TO : _a /lir? t. EMPLOYEE #: DATE: 1„ q . i c6/ <br />Date Service Completed if already completed): SERVICE CODE: (.7 Le j P/E: ib.,C, <br />Fee Amount: 1 52_00 ' ''' Amount Paid Payment Date '").- - 9 • <br />Payment Type (. R Invoice # Check # - — Received By: ,7X__,,. <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)