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APPLICANT'S SIGNATURE: DATE: t- 13 "2-. 0 t <br />I also certify that I have prepared this application a <br />COUNTY Ordinance Codes, Standards, STATE and F <br />d that the work to be performed will be done in <br />ERAL I S. <br />accordance with all SAN JOAQUIN <br />SAN JOALt. IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />C-og T€V2" <br />FACILITY ID # SERVICE REQUEST If <br />.5240o 7/ 3,,2_1_ <br />OWNER/OPERATOR <br />LOIS Pt RtnA NO° AV/E1 CHECK if BILLING ADDRESS D <br />FACILITY NAME 1•11pi4a3S coe.\\; g.61"6vE1>-- <br />SITE ADDRESS <br />20 \ Street Number Direction (3 V. Imo \i`iStre4 Name IV\ C;k4Ctr) CA 535 Zio Cod. <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />P . O 1---crx 539 Street Number Street Name CITY STATE ZIP Wes-V1e CA cis38--4 <br />PHONE #1 EXT. <br />(2o1) (3 -a2-15G <br />APN # LAND USE APPLICATION # <br />PHONE #2 err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE <br />REQUESTOR 542-44/1-e--- CHECK if BILLING ADDRESS III <br />BusiNEss NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX If <br />( ) <br />CITY 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 or <br />activity will be billed to me or my business as identified on this form. <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANA R 0 OTHER AUTHORIZED AGENT 0 <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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: FiirS Cel4krth-itst\ PAYMENT <br />COMMENTS: RECEIVED <br />JAN 1 3 2015 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED By: fro , AM-t ., EMPLOYEE #: DATE: 1/13// cs <br />ASSIGNED TO: <br />1,- 714,QVCW‘-al EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 6 6 / PIE: /66 -• <br />Fee Amount Pai0)130. OD Payment Date Yi Amount: 4/ ;C) <br />Payment Type Type cootsr_i__. Invoice # Check # Received <br />EHD 48-02-025 <br />07 /17/08 SR FORM (Golden Rod)