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ik t I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> MArkd- eco C-3M-7935� <br /> OWNER/OPERATOR 51r (fin 1W� <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME �1 <br /> SITE ADDRESS n/ C a n IPY m 1 ,4 Ve I re, G� 91"3 76 - <br /> UJ Street Numher Direction SVeet Name 6i Zia Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number SVeet Name <br /> CITY STATE ZIP <br /> TrAI <br /> PE#1 EXT. APN# LAND USE APPLICATION# <br /> �� qq - I 23S--os6 <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> ( ) 11 C)IJct) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Go n-ZQ t o (At I u r CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> CGr h ��c o LLC, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY r,, STATE /� ZIP 9s M L <br /> BILLING AC NOWLEDGEMENT: 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,Standard��PA�t= <br /> EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE <br /> PROPERTY/BUSINESS OWNER IJ PERA-U TOR/MALTAGER 11q OTHER AUTHORIZED AGENT µ.t PrP'G(IL M6117{[✓ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required <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 as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. w <br /> TYPE OF SERVICE REQUESTED: F� a AYrftE <br /> COMMENTS: EI VE® <br /> JUN 2 9 2018 <br /> SAN JOAQUIN COUNTY <br /> HSN HIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: `_ t,/� j EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: IL-C) <br /> Fee Amount: G Amount Paid 5' Payment Date <br /> Payment Type. Invoice# Check# Received By: C�j <br /> Ctrn>L�` �b �l 5y 1 fr' <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />