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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT SERVICE REQUEST Type of Business or Property _LC 'S\(\l'ef---1, -1) Clcir\c- --.> kcD VM FACILITY ID # SERVICE REQUEST # OANER / OPERATOR i CHECK if BILLING ADDRESS U :3k----\e-Ne---f--- tt(--31 FACILITY NAM SITE ADDRESS ADDRESS Direction -k 1 \4- ' '' — Stit-N Name Zip Code .7----+R--4 Street Number c.jv HOME or MAILING ADDRESS (If Different from Site Address) yl•-•,e1,--ND \__1("\ - Street Number Street Name CITY CP\ S'-`-'1 \ STATE ZIP N PHONE #1 EXT. 9-f --106 L-A----4L, - APN # I ,16 1 1 LAND USE APPLICATION # PHONE #2 EXT. C— C-- BOS DISTRICT LOCATIONAODE CONTRACTOR / SERVICE REQUESTOR FZ.Q14FSTOR CHECK if BILLING ADDRESO BQ.S4NEss NAME Ks •r(T-14 - \ c -n- - EXT. HOME or MAILING ADAt'ESS '° V.---\ t------) • PVICYNe_k—C-D 1---r\ FAX # ( ) CITY-1/N V_V=.3(.2.)<— \ (..--A_ cA -----:\ k STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Of activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER LF-- OPERATOR / MANAGER Er OTHER AUTHORIZED AGENT 0 If APPLICANT /S not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr Aed to me or my representative. g A.C611,,LV ) TYPE OF SERVICE REQUESTED: .--COct V 0,7 fejer if'? vet hn4 COMMENTS: itio / , `t) J/° 9 6 )515 uu IA D._oc): %Jo ' 2018 0,1,44004, fitio. Rolv,, Cot) l'i DE1,7,..47;41vrY --vyr,tf4ir ACCEPTED BY: _l (4 EMPLOYEE #: DATE: 5- . p_ AS, ASSIGNED TO: 1_101 k a,v2z) EMPLOYEE #: DATE: <3 fi_ /y Date Service Completed (if already completed): SERVICE CODE: 6, (..c. ( P/E: 1 4 ,0 •5 Fee Amount: Ic-roc:CID Amount Paid /c„.") (y) Payment Date 5// // Payment Type Invoice # Check # Received By: DATE: cs ((6, EHD 48-02-025 SR FORM (Golden Rod) 07/17/08