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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />‘2_ a,-cilLt 71- l <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />8 (-t (.2, 1111 Street Number Direction <br />A 0 c <br />Street Name <br />SAN) gZ-Uk.) 0 <br />City <br />Cilt-kb c, <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />cto 1 t,i,()-\--onNI/Ve..‘f `A 4\0e_., Street Number Street Name <br />Crry STATE ZIP <br />GO.,C\ /ilk-,YNC.) CA <br />PHONE #1 EXT. <br />( 6 Sd 2c\- 5-5 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(6S0) 2_. 7 \ (-1 3 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK ff BILLING ADDRESS <br />BusIkEss NAME <br />--0 Ac_.) <br />PHONE # <br />(C-,.) 1-1\--- <br />EXT. <br />- 1 3 <br />HOME or MAILING ADDRESS <br />Ct ) <br />FAX # <br />CITY c <br />S A B-Li 00 STATE ( A ZIP --t"- q 0 (, L <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 />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: Al p j(Ao d r o Eduare/D <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 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 imvided to me or <br />i , I I i' ‘ <br />TYPE OF SERVICE REQUESTED: ROA OA (M \._ V\citaViV\...- <br />Wok.. <br />cn <br />'•iif IT- <br />ie <br />COMMENTS: Sep 2 <br />b, <br />, - <br />84,1,1 <br />Q1 <br />2018 <br />em,QuIA, lieu IF?oN cot,A, <br />7110epAtivt4t 7)' <br />ACCEPTED BY: 1 ., MAAQ <br />1 <br />/10 EMPLOYEE #: DATEC't -- Z Vt <br />ASSIGNED TO: \I , cp, &at EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 00 <br />\ <br /> PIE: likOD-5 <br />Fee Amount: 1 k n Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: 0 9. 12_1 1 -az) <br />my representative. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08