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SAN JOAQUIII COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />Efi-OCVI -0'- 9 <br />SERVICE REQUEST # <br />W 7 9 `S-0 7 <br />OWNER / OPERATOR <br />CHECK if <br />\/ r c.)- N_ lc_., v.,_, c \ (--2:-,c1 c, -2 Ck ii; <br />BILLING ADDRESS <br />FACILITY NAME løz 'Ticc) Coco --m- 3 -c-/,, /14 <br />SITE ADDRESS 7 ._.0 <br />Street Number Direction <br />C...c20__Ct-Ccr I 2 /67 ..)- <br />Street Name <br />c__, <br />'" <br />,,_,, <br />' City `- L Zip Code <br />HOME OF MAILING ADDRESS (If Different from Site Address) <br />) r <br />H-I S D-- _.) \ L e-.. )A - E- Street Number Street Name <br />Cm( i_.,, STATE ,-, ZIP <br />- kr)c 1(--- 0 r--- <br />PHONE #1 #1 Ext APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />( I <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR \ 1 t \ <br />\,) \ CtO r __kc, \iNue s 0. ( 2_ <br />(--) <br />`+' l.._ • <br />CHECK if BILLING ADDRs <br />E/las <br />BUSINESS NAME <br />L DRwt---1,5—kv-F 7-rk -k CO Cc Pr" it) <br />EXT. <br />HOME or MAILING ADDRESS <br />LI LA OA W F <br />FAX # <br />CITY __ ., c 0. L n STATE c f --.., ZIP c-- - „i-, <br />BILLING ACKNOWLEDGEMENT: 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: Wd0 I S \ 7A-ri <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARn,, 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 is provided to me Of <br />my representative. <br />TYPE OF OF SERVICE REQUESTED: RYA \if )!Ef-e,1,-); c4---/o) RECEIVED <br />COMMENTS: <br />,,no irige_ 04 ot.u7) el- AUG 1 5 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />)i-i <br />EMPLOYEE #: DATE: 1 <br />ASSIGNED TO: 771,--) ki (- sr h(r+ z_ EMPLOYEE #: DATE: 3._ j c.-- j <br />Date Service Completed (if already completed): SERVICE CODE: <br />0 (101 I <br />P/E: ) j.,70 <br />Fee Amount:\ ---c—, -_2_- Amount Paid t 52. a) Payment Date S is C.6 <br />Payment Type v 1 Invoice # Check # Received By: e-5)p) <br /> <br />DATE: <br /> <br />/ <br /> <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)