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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property C,hackcr 5 t hoot FACILITY ID # BUSINESS NAME CL_ _I -� Cv( �L. lrckr-htC -a" t-f71�`�' SERVICE REQUEST # LYRO 0 7 OWNER / OPERATOR �`��11 W�\'eg�a�L �t�•.\.�t��A-h�(ta, S��pO `5 CHECKIf BILLING ADDRESS FACILITY NAME �rtb&*ON FAX# ( ) SITE ADDRESS L400 Street Number Direction 1.,1 _ �^ L�.-C�kl 1� t31 (l,Q. ,T11 Stree[ Name l 9.bG�n Ci G;5'1OZ Zi Code ADDRESS (If Different from Site Address) HOME Or MAILING ^ R io . SOV, `L 5(' Street Number Street Name CITY Jioc' 1LT�7 -NC\ STATECAZIP'76'7,61 PHONE #1 EXT. (1v9) 3'TO - 4 8(0 APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR C,}v„IC' w' CAe,gtcJc loterlt 717- (�G. ✓�„v � S�v 5 l�, s � r"�-L CHECK If BILLING ADDRESS BUSINESS NAME CL_ _I -� Cv( �L. lrckr-htC -a" t-f71�`�' 5e -614S PH NE ExT. 340 QScD( HOME or MAILING ADDRESS {?.C)1-5 x 22e)b FAX# ( ) CITY G` r Gf. _. _ _ STATE /I A ZIP q5 2.. 1 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this fo I also certify that I have prepared this app�l,i,,c�ati�o`n d that the wor to b performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S}a ta;utdEDE laws APPLICANT'S SIGNATURE: � `_ I AA DATE: 10-t' — PROPERTY / BUSINESS OWNERIO OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ lIfAPPLICANTisnottheB/utNGPAR proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property 11pcated at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/s&assessment I information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the site time it is �y provided to me or my representative. A N TYPE OF SERVICE REQUESTED: u n'S U V t ti c I V REC CST COMMENTS: OCT 272017 a &O Ham 'd m ACCEPTED BY: h II �I n 1' EMPLOYEE #: DATE: ASSIGNED TO: Nit EMPLOYEE#: DATE: 0 P/ Date Service Completed (if already completed): SERVICE CODE: Pm. I /) lC Fee Amount: y /s 2 Amount Paid $152 Payment Date 5 7 Payment Type (. v av, Invoice # Check # (OO (y 8 Rece ved By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 dl N