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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # -r' " 1 14 / L CHECK if BILLING ADDRESS SERVICE REQUEST # C�2� 78`6OC� l-IOUo2 57oR)_ 1� cr% PHONE# .-/ 1% 7 3 5 3 SU11� 1 HOME Or MAILING ADDRESS 7Z I �! I� �J eST ("Q ('I C BILLING ADDRESS❑ OWNER 1 OPERATOR KU Q U I I�� j J O 1`I r-- S I' n" M i9 i j H I HIL CHECK If r rT 1 Irl FACILITY NAME Jyj 1- I ©V U o Y'1 S �< •7_ d t of same EMPLOYEE#: DATE. -_2. 2.�f SITE ADDRESS 6 2 2 1 I S I-- O N I_ S r d G Cotle 5'Ul+e /DI Street Number Direction Street Name CI ZI city HOME Or MAILING ADDRESS (If Different from Site Address) Check # 3 3 Received By: 7 Street Number Street Name STATE ZIP CITY Ezr. APN # LAND USE APPLICATION # PHONE #1 ( ) % 9 yD 503, BOS DISTgqttgqTT�� LOCATI N CODE PHONE#2 (lV .-. xTm" A / CTi AVT(`F. RF.niWNTOR <.VL\11�L-flilva" v - - /� REQUESTOR I!' 1 R U V I� L- lq - os +- P N r 1 I -r' " 1 14 / L CHECK if BILLING ADDRESS `rel EXT, BUSINESS NAME M 1=' i W (D U O IZ S 1-622-1 PHONE# .-/ 1% 7 3 5 3 SU11� 1 HOME Or MAILING ADDRESS 7Z I �! I� �J eST ("Q ('I C Fax# ( ) CITY S r V C ISTATE C 114 zIP 1 5 Z EMPLOYEMALTH DEPARTMENT d t of same BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorize ager 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 form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 'y - �' lq ZTA / 1""Q DATE: PR RTY I BUSINESS OWNER IAT OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Title If APPLICANT is not the BILLING PARTY Proof of authorization to Sign Is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time, itiMprfffed to me or my representative. , TYPE OF SERVICE REQUESTED: I r V COMMENTS: RECEIVED IM ,EMIIRONIMENNTTAL FEB 2 8 2018 HEALTH DEPARTMENT, SAN JOAQUIN COUNTY ACCEPTED BY: Z'eA is EMPLOYEMALTH DEPARTMENT - EMPLOYEE#: DATE. -_2. 2.�f ASSIGNED TO: Date Service Completed (if a ready completed): -T SERVICE CODE: �d3 PIE: / ' �Amount Paid Fee Amount: �7 � Payment Date s Payment Type � Invoice # Check # 3 3 Received By: 7 SR FORM (Golden Rod) EHD 48-02-025 07/17/08