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I also certify that I have prepared this applicati•n and t <br />COUNTY Ordinance Codes, Standards, STATE/ d F 74".. ,iike • AA.- -Ira <br />DATE: <br />PROPERTY / BUSINESS OWNER <br />If APPLICANT IS Of the BILLING PARTY, proof of authorization to sign is required <br />OPER TOR / M NAGER 0 OTHER AUTHORIZED AGENT 0 <br />e work to be performed will be done in accordance with all SAN JOAQUIN <br />tap \2,s1 <br />Title <br />APPLICANT'S SIGNATURE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />t-A ccoo-1 3 2--- <br />SERVICE REQUEST # <br />s--It2 CDSOD co <br />OWNER / OPERATOR <br />—1-kne C-)Cee. —V---D4t,\(--- \ OC . <br />CHECK if BILLING ADDRESS <br />FACILITY NAME -r-11 e... c.:14,,,eekc -Foie_ \C.._ <br />SITE ADDRESS LO 0 <br />Street Number <br />5 <br />Direction <br />cKA rvi-eui--- <br />Street Name <br />tiD di i <br />Cibi <br />gS-2-cl <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) \ 3 -1. ,2 <br />Street Number WCAksT "T12-e-e- e-0 Street Name <br />CITY k_,0 A i STATE cpr ZIP <br />PHONE #1 EXT. <br />(201 1 0.-- GS.2 <br />APN# LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2Y1 Ig)OD <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 5gr -il tit-co 5 - \N111-t. to 5 CHECK if BILLING ADDRESS <br />BUSINESS NAME The h ,(e_e_. ---t--;kw_lc. PHIGNEI <br />(.y-n <br />EXT. <br />SI 0 - 5 zg 2_ <br />HOME or MAILING ADDRESS <br />‘ t12- \..0 C. uST <br />I Fax # <br />CITY LC d 1 STATE eA ZIP 1:51572_,..A 0 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Of <br />activity will be billed to me or my business as identified on this form. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: -F"CiDej \) 041 CAJ2 vicKof-vp(_, <br />:-.-t-r-itvrcArr— <br />RECEIVED <br />COMMENTS: 4,-2 5"-- i% <br />6 0 JUN 2 5 2019 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: \I ‘ 0A0AQ/A-3 EMPLOYEE #: DATE: <br />ASSIGNED TO: NI . \iN) 1 Q_S eitivka tn EMPLOYEE #: DATE: (0 I S 1 l q <br />Date Service Completed (if already completed): SERVICE CODE: 0(0 1 P/E: <br />Fee Amount: 4 1 2 . 60 Amount Paid 4 k.s . (:,c) Payment Date (0 iS i 1 <br />Payment Typev lage‘,;, A_ Invoice # Check # Received By <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08