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k1g-2, 119•s-4-4 <br /> SAN JOA(AUIN COUNTY ENVIRONMENTAL HEAll JEPARTMENT ` _I oI <br /> SERVICE REQUEST V <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> %' tuce '}0c7 02S 0. <br /> OWNER/OPERATOR <br /> G-,r bye .�✓hfX� CHECK If BILLING ADDRESS� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Diredlon AJ <br /> Sheet NaveGI ZiCotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> "Street Number W W , 1 � • Street Name <br /> CITYWWIA STATE ZIP <br /> PHONE#t EXT. APN# (LAND USE APPLICATION# <br /> qs I 2X CI S 93C <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE uEST R CHECK if BILLING ADDRESS <br /> cr <br /> BUST P NE# EXT. <br /> 23 <br /> HOME Or MAI G A REq� FA%# <br /> CITY STT zip /wC32''l <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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S tofz� <br /> SIGNATURE: Qon— � ' DATE: 11t <br /> PROPERTY I BUSINESS OWNER LJyOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to Sigh IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 025O Cons <br /> COMMENTS: RECEIVE <br /> w 6.4Y <br /> pvoxwc< c .JAN 16 2018 JAN 16 2018 <br /> SAN JOAQUIN COUNTIIENMRONMENTALHEALTH <br /> ENVIRONMENTAL PERMITISERVICES <br /> I ENT <br /> ACCEPTED BY: � EMPLOYEE DATE: <br /> ASSIGNED TO: 1 I�.,-I�(r��. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ('L' PIE: 11'e02— <br /> Fee <br /> 1'e0ZFee Amount: $ 1 s •t2" Amount Paid 5�_ Payment Date <br /> Payment Type G4 ( Invoice# Check# Received By: ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />