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11•7071 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business <br />NI 0p, <br />or Property FACILITY ID # SERVICE REQUEST # <br />r LE- <br />OWNER / OPERATOR <br />CHECK if L A L --T-i, <br />BIL I* LING ADDRESS <br />FACILITY NAME <br />' L'I ‘/C-:1' •,S --t- 1N1E7 CDP->1 L <br />SITE ADDRESS <br />1 I 1 I • Street Number Direction <br />I I I I I E .N KJ `f <br />Stree Name <br />e) Ck-t- 1 T Tc <br />City <br />...S. 2_ I <br />ZiP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />9 C,z)V f ---,_:-./"-E.-7' fc) ,-/ PL_ Street Number _ A Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />70s----/cD3s- <br />AP # <br />Aro - <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT + LoCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />12_ \ ( NA E-Z- CHECK if BiLLING ADDRESS <br />BUSINESS NAME <br />( Lig <br />PHONE #ExT. <br />(;)a-O — 3—S .-./ <br />HOME or MAILING ADDRESS I , ,_, <br />'1°116 Slio—Tuovi_ LL Sf <br />FAX # <br />CITY - A . . . , .- — P-1 rl rs,4 c 3 ct) STATE cA 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 <br />or 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 SIGNATURE: <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the Blum; PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: t 7.......462 ,a) 0165.1 --172„6„.../ c....44e__ c_ Cervet <br />COMMENTS: <br />JR:l N"Nr <br />OCT 2 2 2019 <br />BAN U <br /> <br />ehtwo „ couN.,, <br />blEAL,ThicrAMA „ENTAL ' r <br />nrtrivergr <br />ACCEPTED BY: <br />...V <br />EMPLOYEE #: DATE:. An 77/2„, 1 el <br />DATE <br />/ <br /> ASSIGNED TO: <br />*' <br />EMPLOYEE #: <br />Date Service Completed (if alrea y completed): SERVICE CODE: qv' P/ E:4:2_,0 I <br />Fee Amount: Amount Paid 5502+ .-- Payment bate <br />Oct <br />Payment Type 0 Invoice # Check # i(p (6 B Received By: <br />DATE: 1012_-z_ I <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 1 1/17/2003