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DATE: 3 - I I <br />OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />APPLICANT'S SIGNATUR <br />PROPERTY / BUSINESS OWNER 0 <br />dn-4A <br />SAN JOAQUi. 20UNTY ENVIRONMENTAL HEALTh 2,PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />-FAO() 2 LI 1-01 l <br />SERVICE REQUEST # <br />covl -IL( <br />OWNER! OPERATOR <br />IV i\CtICIC) ruail o / Mi (ki t7U2_11-4,2 5 CHECK if BILLING ADDRESS <br />FACILITY NAME <br />—t-tx Oen A LL Koi 1_1_,C, <br />SITE AD ESS leit 1 <br />Street Number <br />S <br />Direction <br />*--1 -4-VA A '' . <br />Street Name i\ADCUS-1—C) City 1 -S' 1 ip ode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />-91 OCt Ckqfbant D c Street Number Street Name <br />CITY <br />li \KT)24V0 <br />STATE c IN ZIP 0,k,_--) 3 9-0 <br />PHONE #1 EXT. <br />b7CCP 910- 3rr-k3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />601 ) . ri3t L-1,5t5 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR — <br />V-421 nai(tn -1--v)Q y\A-ei5 <br />CHECK if BILLING ADDRESS <br />gi - lS:ASra <br />V—k,A>\V0d(11C <br /> <br />HOME or1AILING <br /> <br />ADDRESS <br />P Ex T. <br />lbq C\ CAVNAMk Dr ,. <br />v Ft ( ) <br />CITY 1\1\0102..frk0 STATE el\ <br />) <br />ZIP Cl <br />:3 -0 <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 <br />or 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, TE and FEDERAL laws. <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />1 <br />TYPE OF SERVICE REQUESTED: -E,DOCk 2\/O/1;lete tvtc)pa.vvtyvL) <br />. .4.1rmeivr <br />CoCOMMENTS: <br />avokcy oc Ov4AgyA,kA)-ile MAR 31 2020 sAlvJo AQ,, EAvilio N"co HEALTH0 „,mEN uNryTAL <br />i-ARrmaolir <br />var, - ...is., <br />ACCEPTED BY: \I M0/49,0,-3 EMPLOYEE #: DATE: ••• 1 ZO <br />ASSIGNED TO: S C5VWA...._ EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 Lt9 I PIE: 1003 <br />Fee Amount: 4 ,-2 __... Amount Paid ( ,--- Payment Date L5{ 5\ .-c;, <br />Payment Type a JA) Invoice # Check # Received By: MA <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003