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SAN JOAQUL 20UNTY ENVIRONMENTAL HEALTH _ —PARTMENT <br />SERVICE REQUEST <br />Type of Business or <br />l,,,,'.i 1-6-5 to nd <br />Property <br />PGICI- ilte i if He vki., c <br />FACILITY ID # <br />NC() i 7 8" 9 q <br />SERVICE REQUEST # <br />.,::,2 (yo i (No 1 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME j . <br />v.. ,• . !kit- ,11- tic30-6S <br />SITE ADDRESS <br />il5 I Street Number <br />(..,-.. <br />Direction <br />___e5.11-, II 'cid 18 -P s' 44 ar t <br />• ‘l Street Name ti C ) V), City <br />et -??- 53 <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 Err. APN # LAND USE APPLICATION # <br />PHONE #2 Err. PHONE BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR v . i <br />1 - vig A44.1.k :4, iney CHECK if BILLING ADDRESS r171- )46k <br />BUSINESS NAME <br />P00/ i)k-s- Aec /. ,/,i <br />PHONE # <br />( 2C,c1 ) 6 S a — 34.q 3 <br />EXT. <br />HOME Of MAILING ADDRESS / , <br />too c c ri;:--; k l 4 I.C(• <br />FAX # <br />( ) <br />CITY STATE ,e''' (...._ 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 FEDERAk. laws <br />OTHER AUTHORIZED AGENTIk ;`) e 1,4 i/t-e f <br />If APPLICANT is not the BILLING 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 />, 1 c <br />TYPE OF SERVICE REQUESTED: I c i-'1 i) 11 (k_e — ---c-- vv\-...6-(-(- \ PAYMENT <br />COMMENTS: RECEIVED <br />A -R 1 0 2014 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HIALTh Dapairmatni <br />ACCEPTED BY: N , c„,i/A1 0 , EMPLOYEE #: ,-) c, 7 0 DATE: 6._ , 311(.4_. <br />I— i i , <br />ASSIGNED TO : xi p L74 _65,1 EMPLOYEE #: / 4.1c DATE: <br />Date Service Completed (if already completed): SERVICE CODE: (--) 2_ 2- PIE: 3o <br />Fee Amount Paid Amount: ..,t7 _..., ?) --Payment Date 121/44)//.411 <br />Payment Type (/ Invoice # Check # 73,2:-7 A Received By:4_42 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />CO 1'6\ <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNERID OPERATOR / MANAGER 0 <br />DATE: