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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTH Di-'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />,--- <br />)706 a -Th UC,IC_ <br />FACILITY ID # SERVICE REQUEST # <br />—Gg bbig 92-6 <br />OWNER / OPERATOR ' <br />K c (...) <br />CHECK if BILLING ADDRESS <br />, FACILITY NAME La Co <br /> it bR079Pq Ini,, <br />SITE ADDRESS <br />M00 Street Number C • <br />Direction iA Sr LU okir Street Na e S7V)Ckieh Cltv q c -QCS Zip Code <br />HOME or MAILING ADDRESS (If (Afferent from Site Address) <br />a . m etiq k Si- Street Number C 1-) Street Name <br />CITY (- • <br />'AOC }CAM STATE c /9 ZIP <br />PHONE #1 #1 Exr. <br />(X / ) tilg 52C) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(9401 ) 91(7 35Aci BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REOUESTOR 1 z _ ' <br />Na ç ‘ RC,%1 cakeelk) CHECK if BILLING ADDRESS <br />BUSINESS NAME L ,, , \ _ci\. a litYlti P NE # „ , xE T. <br />(H209° )tt g351-(.) <br />FAX # <br />( ) <br />HOME Or MAILING ADDRESS <br />? .9, e LAAcesl ) SA-- <br />CITY Sko STATE Clei ZIP v K-2. ,s-- <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 FED- L <br /> DATE: 11(40 <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. <br />TYPE OF SERVICE REQUESTED: iCed Ve /14 - 1 f'e 11-)Gret-i PAYMENT <br />COMMENTS: RECEIVED <br />rrli il,R 1 6 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />...)./td <br />EMPLOYEE #: DATE: 3/05 Ak2 <br />ASSIGNED TO: Lovri Hurl_ EMPLOYEE #: DATE: NI to ( I (e2 <br />Date Service Completed (if already completed): SERVICE CODE: Lccf:x4, I P/E: <br />Fee Amount: AM •0-1) Amount Paid —3 0 ( 2 L) Payment Date <br />Payment Type r i Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)