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SAN JOAQUIN Coq ENVIRONMENTAL HEALTH DEPA "TMENT <br />g/rERVICE REQUEST <br />Type of Business or Property ,J <br />1 CO-Orl C\kiio <br />FACILITY ID # <br />-rA 00313 o -zs <br />SERVICE REQUEST # <br />OD%.3 Du 0 <br />OWNER! OPERATOR .---- <br />3 1 V , '',TC‘11( ., Cllf,tel C16)° <br />CHECK if BILLING ADDRESS <br />FACILITY NAME p ..i c-favi t) , <br />C11)(0 <br />SITE ADDRESS 90 4 Li <br />Street Number Direction <br />)104 <br />.... I iitAs I e---/ Tk,- <br />Street Name <br />3 to Ci: i-cii <br />City <br />95 2 / q <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 />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i <br />C'qv 5-1-13NO 01 , 113 'C. <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME , i c rr. <br />M <br /> <br />6 0 0 e. akIJ ecOl F)ct_Sf 43 PHONE # <br />(?C') <br />Err. <br />72 7 - <br />HOME HOME or MAILING ADDRESS 3570 I:, AA , <br />14 t klier Ave- <br />FAX # <br />( ) <br />CITY STATE z ZIP ‹isec 5 <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 andtjat_lhe wo rformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an ECDERAL wS. <br />APPLICANT'S SIGNATURE: DATE: I Z - t37- cc) <br /> <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT‘il Lo t rat-710 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <br />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 />TYPE OF SERVICE REQUESTED: c,e-pico te.1 5 udi uti iii, fr f),-,C, 1 <br />COMMENTS: - SUU i inlkii) 1 " 1°0 LA `-`°' II be- l'"---/o/ctSt-e(?ei clhol he Lc. <br />be '10 SMI le d , <br />draio pAyfoi rei <br />RECEIVED <br />DEC 18 2020 <br />WritAlg th-IN,5Y <br />TH ARMtn tIATE DEP - <br />0 <br />I <br />ACCEPTED BY: \I. ti\M\ADAW EMPLOYEE #: <br />ASSIGNED TO: \I , !.ea 1410-617v__, EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: 52_ PIE: 300z <br />.17-2,9 Fee Amount:4, 50'4 — Amount Paid .4( 0 ii Payment Date <br />Payment Type Invoice # Check # pf ‘,,, -7 Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003