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SAN JOAQUIOCOUNTY ENVIRONMENTAL HEALTH 0111ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 6l, S Lon 95 2 CO 7 400,-3, <br /> OWNER/OPERATOR � � CHECK if BILLING ADDRESS <br /> \A\ mhJ <br /> FACILITY NAME <br /> )IS U �Au�n owok WA <br /> SITE ADDRESS `n�/' v'' P /j� q��J <br /> Street Number Direction V ��� ✓�Ci'€et� ���C�i ��-" Zi Cod✓eXJ <br /> HOME Or MA LING ADDRESS (If Different from Site Address) <br /> 3'I s_ " Uu sl�etl Ikkoy�streetNumber Street Name gS2�2 <br /> CITY.� STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# CJ C <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE. <br /> ( ) <br /> CQNTF ACTOR/ SE.RV?CE R—E.QUESTOR <br /> REQUESTOR n <br /> V�n CHECK if BILLING ADDRESS <br /> # <br /> BUSINESS NAME C, � 1 1 PHONE EXT.in ' O S(A UGh 01r0?A- �_SI (o <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ao <br /> CA�n STATE ZIP CT�17 I <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 /> 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 an F to s. / <br /> IAPPLICANT'S SIGNATURE: DATE: <br /> `PROPERTY/BUSINESS OWNER EY OPERATOR f MAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> A'v T HvrciZATiON Tv RELEASE iivr vRinATiON: Whenapplicable, 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 /> t0 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: 7 <br /> COMMENTS: PAYMENT <br /> a hoar. RECEIVED <br /> 1 1 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: _ KfALT1. S " <br /> ASSIGNED TO: - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE COOP PIE: 1-/1 U-� <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type =AS Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />