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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />T7A'0 023 \ g <br />SERVICE REQUEST # <br />0 0-11(1 L-11 <br />OWNER / OPERATOR,--) i <br />CHECK if <br />ri) VA C(') )0 noAhci PA (2-0d C c4 2, <br />BILLING ADDRESS <br />, FACILITY NAME ---1--pt C i Fr ( 0 N-\- -.. 'IA C.4.- qiZi)17 1--t V, <br />SITE ADDRESS .7 el 00 <br />Street Number Direction Streetillslame City Zip Code <br />HOME or WILING ADDRE S (If Different from Site Address) <br />C/N A-CYO3 (\_1119 Street Number Street Name <br />CITY, r <br />-t•oc Kko A <br />STATE c A ZIP <br />9 <br />PHONE #1 EXT. <br />TOO `)' — c36)1(.0 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORn i <br />L( CA (.)nGir\ (L oci V 1 c'e 2 <br />CHECK if BILLING ADDRESS <br />TC,i CoS cA <br />BUSINESS NAME PHONF <br />?60 1\ Af' <br /># <br />cc,1) <br />EXT. <br />53(16 <br />HOME or MAILING ADDRESS 3( . 4 r\ <br />LI Af f \--e-rC ( A P c L ki <br />FAX # <br />( ) <br />CITY c":„-kic \SAC4r\ STATE C A ZIP q 5,..Q.15 <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 Of <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- nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE,....! . S. <br />APPLICANT'S SIGNATURE: DATE: LP t <br />PROPERTY / BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICAN S not the BILLING PARTY, proof of authorization to sign is required <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 iArovided to me or <br />TYPE OF SERVICE REQUESTED: --D 0 ck \i'-e Vi (.1% c .1 111c,y9 e ck.v-‘. <br />COMMENTS: C 0 c, 0 .p . Dec <br /> 0 s <br />`944; .10A 2018 <br />-eic-171_,R0A7fivc <br />..--4R7.,,,44 • , <br />"rfk-4/7. <br />ACCEPTED BY: N.,1 nil, 6 ,/,-(2,1tri 0 EMPLOYEE #: DATE: V2,_ Os..1 <br />ASSIGNED TO: \/ . -A 0-e1W2 (1 j) EMPLOYEE #: DATE: '.7....- 0 c ---q. <br />Date Service Completed (if already completed): SERVICE CODE: 60 PIE: <br />Fee Amount: 4 \ 2 . D'D Amount Paid ' / — Payment Date -1157/ 3 <br />Payment Type Invoice # Check # Received By: <br />my representative. <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)