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APPLICANT'S SIGNATURE <br />PROPERTY I BUSINESS OWNER 0 <br />DATE: <br />PERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />312 00N01.) <br />OWNER / OPERATOR <br />0 Vtym cpy-a, CHECK if BILLING ADDRESS <br />• <br />FACILITY NAME <br />SITE ADDRESS C\ 2,2_ <br />Street Number Direction <br />1)0‘,11 4-L. <br />Street Name <br />s.-(-06-v-*--0(\ <br />City <br />S2 \' <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(2o° ) '-\O\ -'Rol <br />APN # <br />to -0-to- 32-0 - Ob alb <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(245))) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r1 , <br />OCaitcx )e4' CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />(2,09 ) (0 1 -, 61 1 3 <br />EX T . <br />HOME or MAILING ADI;MESS 1 <br />CA 22- Wf -\\--R._ 01,..V\i- <br />FAX # <br />( 1 <br />STATE cAA ZIP IC\ s 2 \ 5 <br />CITY SkbC-rTh <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 • i T ilayttFEDERAL laws. <br />PAYMENT <br />8-8- 22. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title RECEIVED <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 akvesOnan2022 <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. .AN JOAQUIN COUNTY <br />TAL <br />MENT <br />... <br />TYPE OF SERVICE REQUESTED , 0,--e--1,--4er --.7- S 17 6-As (.14,;(-1,EA—LITH D-EPA-R. <br />COMMENTS: / 61,,t fi."./C-flist17‘, --r___ 01.7 ,5y,s'mfrt i.t <br />gr A*,ailer-3 ele-ec1411.c.--, 011( ft ... / <br />/ /1..G.--rve....64,..... --/-e, (-1,.-ef-t/e.._ c:_o_c pi, fz-0.-7.1... r- l' _SV-tori-YC-.- <br />/1/0 .r.cl-c-- /A3,----1.t.4-14-s- /11/-/ #1.-1- f`e(kt, fli. <br />9-- L f i-no e t <br />c <br />S'y -071e-,'"" • <br />DATE: 4/72 <br />DATE: <br />ACCEPTED BY: ;Lyt c Cul_ C EMPLOYEE #: el 9 F 7 <br />ASSIGNED TO: C-et r -41 r‘ EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: 06, i PIE: y2_4 2__ <br />Fee Amount: 41‘ /S-6 Amount Paid *,, i_S"Z Payment Date Lt/ <br />Payment Type V [ S )q- Invoice # Cbea # is-2,C .-q 1 7 ,3 Received By:i‘tfil <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)