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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />_ <br />(.... SERVICE REQUEST # <br />\2)R ciLvt6 y 5 <br />OWNER / OPERATOR <br />A ON-V-c,cLi (' C_Ix--11,1J,J1c,c)/7 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />C.A U'E_L-1\'--- OP_ PL-/ <br />I 7- I:1- "-'St-17eet Number Direction <br />SITE ADDRi,_., <br /> <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS Of Different from Site„Ad4dilsV <br />L - - LI q-ci- <br />Street Number <br />iLystx- p\o,t1-6Kfc., /2_0 <br />Z ,`,044,0 Street Name <br />, N -,:-I i: ,_)'u <br />CITY STATE ZIP <br />‘31-bC1-0-61 L.-I, <br />PHONE #1#1 EXT. <br />(204) L-17-I - 02-e1-4 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ?VI ) 6 62. - ?:5't <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />P ON --5C-QT-c) C_A5-FAKI-c9 A <br />_ <br />CHECK if BILLING ADDRESSa <br />BUSINESS NAME <br />(1_,(::\ --LiEL-P\S 06- A L i / <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />LL ?-Cl 6( /L.) "--- 1- \ Cs-acyure_., 0 (Th <br />FAX # <br />( ) <br />CITY <br />1- STATE ,_ 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 nd Firc))ERAL law0047k) <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 is provided to me or <br />my representative. DAVRAMT <br />TYPE OF SERVICE REQUESTED: 10 0 / <br />.• M. • ••••• • MI • <br />1 i tan Cill C I' RECEIVED <br />COMMENTS: <br />MAY 0 8 2019 <br />SAN JOAQUIN COUNT <br />ENVIRONMENTAL <br />HEALTH DEPARTMEN <br />ACCEPTED BY: LO (Ar (A_ , EMPLOYEE #: Tic -; 0 DATE: 5 /,F ig <br />ASSIGNED TO: 1,4,2,d exhi ('1e L., EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: i E: )(A o i <br />Fee Amount: 6, .00 Amount Paid Payment Date <br />7 <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: DATE: 05-08- ig <br />EH D 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)