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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST --Rt:NEW A --i2( -. D A komi 3S-09
<br />Type of Business or Property i .., . iA/II,;cei 1 i ee
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<br />
<br />1g 'J /17,fie /(e.7-<. I if,:‘ e .';G: i'r
<br />FACILITY ID #
<br />, y--,pi Cc)21 7-425
<br />SERVICE REQUEST #
<br />512-0 XIG29
<br />OWNER! OPERATOR ,--
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<br />CHECK if , _
<br />BILLING ADDRESS V
<br />FACILITY NAME
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<br />SITE ADDRESS
<br />,-' Street Number
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<br />Direction I, ...,- c' m ,
<br />I Street Name City Zip Code
<br />HOME Or MAILING ADDRESS (If Different from Site Address).
<br />/ f'_•i'ci c'_://y l. Ai Street Number t- 1/ 4 Street Name
<br />CITY .. -- ( STATE ZIP
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<br />PHONE #1 EXT.
<br />( :',4 •:::q - 1 6 1
<br />APN #
<br />21a Oil LA
<br />LAND USE APPLICATION #
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<br />1-T.:,
<br />PHONE #2 #2 Ext
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<br />BOS DISTRICT — i i
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<br />LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR , z,
<br />2i ii Ai ,i, 4 0,7 , r t. 1,___ CHECK if BILLING ADDRELv
<br />BUSINESS NAME . , 4 ,1- i 1 1 , e itA inc. . 'DAM d LIQA / I
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<br />024,.<q- /6' f
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<br />HOME or MAILING ADDRESS ;
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<br />V . .,--
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<br />FAX #
<br />caq.) 8 - „,)itS
<br />CITY
<br />/ 1 7 /-17) re c 4 , STATE ('1 ZIP (/5 -33 e.
<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 />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(
<br />PROPERTY! BUSINESS OWNER X/ OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0
<br />If APPLICANT is 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 or
<br />my representative.
<br />TYPE OF SERVICE REQUESTED: F7e A! /1) / 77:-?1* --71,1 e..,4:7-a )4/ Z PAYMENT
<br />COMMENTS:
<br />, -Ae ' ' 'ck 'al. r 6 II k r - RECEIVED
<br />APR 1 1 2018
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL
<br />HEALTHiETRTMENT
<br />DATE:
<br />DATE: 4,101147
<br />ACCEPTED BY:
<br />//LC i7LC t
<br />EMPLOYEE #:
<br />ASSIGNED TO: a ajar? EMPLOYEE #:
<br />Date Service Completed (if already completed): SERVICE CODE: ao ( P/E: 110 0 -5
<br />Fee Amount: , yi /6z ,-.),____ Amount Paid Payment Date Li , ( i ,c?
<br />Payment Type L Invoice # Check # Received By: Z .
<br />DATE:/1
<br />Title
<br />END 48-02-025
<br />07/17/08
<br />SR FORM (Golden Rod)
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