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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Ct Co TIOC <br />FACILITY ID # <br />OeL\1) <br />SERVICE REQUEST # <br />sect 7 D,Ia r <br />OWNER /OPERATORn <br />0 CiS M , V-r8kii'ci c, e 2- s _ CHECK if BILLING ADDRESS <br />---r-, FACILITY NAME P V CG c)c' E <br />SITE ADDRESS ., <br />-grekKumber Direction e_ vo(644 , cc-occr[cf) tV <br />q152V6- <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />l <br />Street Name <br />Cm(eco(,.._ Noc ir, (ATE <br />pNE #1 EXT. <br />f ef? L )---- (90(1) <br />APN# LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 111 (. <br />S CHECK if BILLING ADDRESS <br />VJVA c> Aill . Q-odkrpc.) e <br />NAME 13,4dONE # <br />'t",c.,c) <br />UT. BUSINESS --1-- <br />(CA CO CS t 'e_ or'N <br />HOmi nviG acc_TDR,§S <br />L-1 O fri <br />FAX # <br />c lOcii\ r ATATE <br />CI5Zi ( 5 <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 ork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F <br />APPLICANT'S SIGNATURE: DATE: (c lo t ( <br />,.‘,.PROPERTY / BUSINESS OWNERD OPERATOR / NAGER 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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: '\::------0 oa , v T v-h i rl ,e._ PAYMENT iy)c CC-V(00 <br />COMMENTS: RECEIVED <br />OCT 0 1 2015 <br />SAN JOAQUIN COUN <br />ENVIROMENTAL <br />HEALTH OEPARTMEI <br />ACCEPTED BY:(7...A. i'D EMPLOYEE #: -- DATE: iC) , 1 _ i ,....) <br />ASSIGNED TO: LT 0 y 1' h EMPLOYEE #: - DATE: / c -- 1 _ / <br />Date Date Service Compieted (if already completed): <br />1 <br />I SERVICE CODE: c-) (4-, I i I) / E: <br />Fee Amount: i -2114) Amount Paid / r Payment Date / t, /, /r <br />Payment Type Invoice # Check # Received By: <br />EFID 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)