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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �J aide 52OO-7-7273 <br /> OW ER/OPERATOR <br /> 116 ? S' CHECK If BILLING ADDRESS <br /> 4FACILITY NAME/ rox- Jo '* JA95-6q0 <br /> SITE/A/��D//D��RESS (,( I �tl_S ck f e_ <br /> W Street Number Direction 1 4� �AhOa a �'p IvIt, ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2G3S-W'AZ <br /> vrSl <br /> V0v%A— '&+. Street Number Street Name <br /> CITY (rF�Gh �„ TATE g5Zo3 <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> ;3A ) 663--?DQJ <br /> PHONE#2O Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) (0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> rIC(iJI,IV� � „� <br /> BUSINESS NAME PHONE# Exr' <br /> R1L'q0&-A osL-��' .7 — <br /> HOME or MAILING ADDR S FAX# <br /> t n t Se <br /> CITY STATE /Irk 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 /> 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 d EDERAL laws. <br /> -GAPPLICANT'S SIGNATURE: DATE:41' <br /> 1 �0 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titre <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon a5 it i5 available and at the same time It IS provided to me Or <br /> my representative. <br /> �A <br /> r00), IJ G�t[- eC I ENT <br /> TYPE OF SERVICE REQUESTED: lD.h <br /> COMMENTS: Y 11=_I vllc u <br /> APR [ 1 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: j' IAf�G'ZI\ EMPLOYEE#: DATE: G-I-ZI- 17 <br /> ASSIGNED TO: (1 �1_ EMPLOYEE#; DATE: <br /> Date Service Completed`(if already completed): SERVICE CODE: 06( PIE: <br /> Fee Amount: l COO Amount Paid 13 5 • m Payment Date <br /> Payment Type CGS Invoice# Check# .�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />