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SAN JOAQUIN ,..,OUNTY ENVIRONMENTAL HEALTH DEr ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />7C-t CO c r 1 A 3'UC-N 7)c)/C e <br />FACILITY ID # <br />po- ob.D_D_.3 ,-b- _ <br />SERVICE REQUEST # <br />SROLY-79493 <br />OWNER! OPERATOR <br />CHECK if <br />JeCC 1'z BILLING ADDRESS <br />NAME FACILITY NAME <br />.,(c-r..•.--(744-4:7-c%=(*."1- i ace) E-I 49 IAA •Dikie-e <br />SITE ADDRESS <br />_ /1--/Ciltte'r‘Niumber t YO 0 DIrject 5 ioc ick /, 14- Street Name <br />____,C71 <br />------- 11 Fsgtf° 5 m C e <br />f Different from Site Address) HOME Or MAILING ADDRESS (f <br />o /KO / SU / Y A c.,, Street Number Street Name <br />CITY STATE ZIP <br />C 'hDC V k )r CA 95 E-0 5 <br />PHONE #1 EXT. <br />(Zo <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />r CHECK if BILLING ADDRED:F <br />BUSIN SS NAME <br />T a co5 e 1 A (.)c... xi c e <br />PHONE # <br />(/(D,P)q <br />EXT. <br />HOME or MAILING ADDRESS <br />U i 1 0 A V -e- <br />FAX # <br />( ) <br />CITY c , oc 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 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />CY YC <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: Fcx) d \.) pkiti, I _e_ i ,15(.....wc4-1 (-) FAT MENT <br />COMMENTS: <br />CA-Yan9 t. C5-c 0.1/Z11 e'r— <br />RECEIVED <br />APR 1 1 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT; <br />ACCEPTED By: S..e..a rci EMPLOYEE #: DATE: L4 _ J) ,„_/ cB <br />ASSIGNED TO: iki. 0 n h EMPLOYEE #: DATE: _ / i _ / <br />Date Service Completed (if already completed): SERVICE CODE: 0 (o) PIE: t co <br />Fee Amount: Amount: 1 2.....,t)b Amount Paid , Payment Date ty . il . i <br />Payment Type ,t c 1 ,( Invoice # Check # Received By: <br />DATE: nz-ri /1-20g <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08