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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LaPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID // <br />fPt bbrIliao 2- <br />SERVICE REQUEST # <br />5R Do-3 TRU? <br />OWNER/OPERATOR ft i co <br />?Li UCta CqUP\-erD CHECK if BILLING ADDRESS <br />FACILITY NAME El_ <br />\ " <br />c- <br />.-lruitat'IS-e1 # 512-q-2_11 I <br />SITE ADDRESS 7 50 <br />Street Number <br />S <br />Direction <br />Ccux - f--)10- St 51-c)c__: <br />City <br />952_03 <br />Zip Code Street Name <br />HOME Or MAILING ADDRESS (If Different from Site Address) g t -. -i- <br />Street Number <br />5 a y but resco c 1 ri <br />Street Name <br />STATE ZIP <br />CITY 2 1 2_ <br />PHONE #1 Ext ' <br />( 2CfP 2-H2j- 3 35 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR F\ ci _ 0 <br />L t CY" El 0-erne-rt.) CHECK if BILLING ADDRESS <br />BUSINESS NAME e <br />L (---Iyoll,caS-e 1-4- S-12:±2ii- ( <br />PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS <br />6CA r ha nes co dr- <br />FAX # <br />( ) <br />CiTY St004--A-Z-- <br />STATE clnt ZIP q scit,2_ <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 that the wor to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, d FEDERAL laws <br />APPLICANT'S SIGNATURE: )2-e12-44/62 DATE: 2-2 /Er <br />PROPERTY / BUSINESS OWNER, g OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 i <br />If APPLICANT S not the BILLING PARTY, 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 />— .. <br />TYPE OF SERVICE REQUESTED: 1 Le b-2_ riDo clk C rn S u H-CiLti or-) RECEIVED <br />COMMENTS: <br />C-Cri S U I +a:1-i C-)r- (Own-Q--r 'DMA() rEB Z 3 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:.. <br />-C\ - VY\DIAD EMPLOYEE #: DATE: .2_ I 2,3/ it <br />ASSIGNED TO: it• EMPLOYEE #: DATE: 2.123 I I r <br />Date Service Comple ed (if already completed): SERVICE CODE: (9 ( 0 t PIE: [ (f) b z__ <br />Fee Amount: 1 i3 "Locv Amount Paid Payment Date /2 -31 ( S> <br />Payment Type ....4' Invoice # Check # Received By: 77- <_ <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)