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APPLICANT'S SIGNATURE <br />PROPERTY! BUSINESS OWNER <br /> <br />(4R <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I.,cPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />'P. ° ° ° \I •Q 11,ck <br />FACILITY ID # SERVICE REONEST # . <br />5(z-C6-71 40 5`3 <br />OWNER / OPATOR <br />1. VIC i) N CHECK if UL <br />-- <br />BILLING ADDRESS <br />FACILITY NAME --\-- Ls , L <br /> <br />Ylkilil X'42 01 CI <br />SITE Armor,- <br />I 0 LI 1 _ _greet Ntker Direction jopho .. alefii 2— (,,,,c;ci - , <br />HOME ((r TLTTDRESS (If-Bifferert from Site Addrss) <br />Street Number Street Name <br />CITY /EI)11E d2 2... 1 <br />PHONE #1 Exr. <br />( \Zc (c) (0 11) - 61 q <br />APN # /L02 ---6C.,) LAND USE APPLICATION ti <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />(i) h <br />CHECK if BILLING ADDRESS a <br />BUSINESS NAME 1--,,,k,fl) CA 6 0( <br />P(RigNE #4 <br />,=6---) (l) <br />EXT. <br />1 <br />HOME or MAILINO ALID(RIBS --i— <br />1 6 e n 1 r <br />FAX # <br />( ) <br />CITY <br />' 6c Om CTIE ZIP Q c2 (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 work to be performed will be done in accordance with all BAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST TE and FEDERAL laws. <br />MANAGER 0 <br /> DATE: <br />OTHER AUTHORIZED AGENT 0 <br />- (7 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br /> <br />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 tie it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: .}------etti \,) e,41 i c] e, 1 r-) 5e2c-j-icy) ?Pli,..iiS1PAYMENT <br /> <br />IOC AgCEIVED COMMENT S: <br />\ <br />epalq e of- -cum er 0 0 1 8 2018 <br />\3- 1r4- 028,0gotigN COUNTY <br />-S10s-0SMWIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: _ jf ri:A EMPLOYEE #: DATE: <br />ASSIGNED TO: (-_—_.10 h ("-...k111.-1- -4- EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/E: <br />Fee Amount: Amount Paid s k s 2 . c_t, Payment Date <br />Payment Type _ Invoice # Check # Received By:;) , <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)