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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />OD 2-S?)(19 <br />SERVICE REQUEST # <br />S IQ° 0 7(p8 3 c3, <br />OMAR / OPERATOR <br />&/ e---/ /') CHECK if BILLING ADDRESS <br />FACILITY NAME 6 / NR y fct i iio yroS Rc /7<i/e) Sc c <br />SITE ADDRESS <br />7 0 0 7 57- Street Number Direction I Street Name Olehtt° 5— lp 9 Cod <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/ 7/) 6, . K irle :R Street Number L-5---„( 6-- Street Name <br />Crry <br />(17 . <br />STATE (,....4 ZIP ,G., <br />la C) --q61 <br />PHONE #1 Exr. <br />7] Z 937? <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR A t)/ (cA 1 (fc: r? d CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />0 ,irfr_y(--(cfpto ())-tf6)-. ge t(e_/1 0 c = <br />PHONE# ___, ,,, ,, ___, EXT. <br />ch. p 7/...L. yS 77 <br />HOME or MAILING ADDRESS„-- 4, 1 FAX # <br />ciTy 4 Dct) , STATE/ f ZIP 99-zi./D <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, ST nd F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 2 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <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 time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: ft) (A Ve/ht(A6 Insrafjoi IPAY NI7WIE-' <br />COMMENTS: RECEIVED <br />FEB Z if 2017 <br />SAN <br />HEALTH <br /> <br />ENVIRONMENTAL <br />., o A Dci Eu piN A RCTOU <br />DEPARTMENT <br />NT Y T <br />ACCEPTED BY: Ar g ew vi war k„h0 44_, EMPLOYEE #: DATE: <br />ASSIGNED TO: 140(otuorle, biohareS EMPLOYEE #: DATE: 3_, <br />c <br />2,,t4 i 1 -7 <br />Date Service Completed (if already completed): SERVICE CODE: NE: Rol, <br />Fee Amount: AA q Amount Paid Payment Date -Th ,/,Th , I r , 7 <br />Payment Type <br />c)('' <br />Invoice # Check # Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08