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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Propert y r--- _ FACILITY ID # <br />InW <br /> SERVICE REQUEST # <br />,C) ,.'fQ0()(2,q <br />OWNER / OPERATOR <br />17-4 /1490/ 5 (emfi)i /74 )4--_-„„sto 4. CHECK if BILLING ADDRESS <br /> <br />FACILITY NAMEZI r- i.) / / <br /> <br />P. o <br />SITE ADDRESS /9g <br />s4eet Number Direction DA Ve ek. to tie Street Name / <br />: 4 ek7:0-ii City Zip Code <br />HOME DT MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY <br />a In kr77' Al 0 7-- -eki in <br />STATE ZIP <br />A Aloe 14--e ,l'44 , <br />PHONE;#i Ex-r. APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />Ii BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE 1RE UESTOR <br />REQUESTOR <br />Ale, CHECK if BILLING ADDRESS <br />BUSINESS NAME ---.. <br />31 (-66 I toe 77e?.5. PHOK # , ( rio) ,• 7-6 717 <br />Err. <br />-7 e//*/* <br />HOME or MAILING ADDRESS )FAO A (wec) „,..-1._ ,,,x2:e e i , (-- <br />CITY STATE 1:f.yi ZIP ' )4'Crt) <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 be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and Fr, RAL laws <br />APPLICANT'S SIGNATURE: <br />/1.' <br />DATE: ///,./4) <br />PROPERTY / BUSINESS OVVNER 0 j/ PERATOR / MANAGER 0 <br /> <br />OTHER AUTHORIZED AGENT 0 C4 (rie-fiert, .--e•Q_ rti --__) <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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: k/20 / ee,/4---S62k <br />,2„..• „Tr mE N , <br />' iNt CE7 V. <br />COMMENTS: Et <br />NOV 2 3 2020 54N J04 , <br />t.i .ENviii8IALdr CouN T A L TH D ,, ENTA L <br />LI-A RTAIENT <br />ACCEPTED By: cl-a'--12 rtett,A-r- <br />ASSIGNED TO: <br /> <br />k, A-rted Ca Ali) 117TA. <br />EMPLOYEE #: b z( -3 DATE: I I I 2, ) <br />EMPLOYEE #: (ezi 3 DATE: tt E3 <br /> 0 <br />Date Service Completed (if already completed): SERVICE CODE: _ /12) P / : • 0 i <br />Fee Amount: Er)04 Amount Pa10-364707) Payment Date 8 2,..t.-_,0 <br />Payment Type 04,e,41-1- Invoice # Check # Received y: <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 a(1)Aff <br />Z47 <br />1 1 .1 935'c <br />SR FORM (Golden Rod)