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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property FACILITY ID # SERVICE REQUEST #
<br />SRON -g 1 it
<br />OWNER! OPERATOR -----
<br />(rnifillti *4
<br />CHECK if BILLING ADDRESS
<br />FACILITY NAME
<br />--,301/4:)/ •727647- 7im/2Ke-,-,7-
<br />SITE ADDRESS / •,-/ 7-- (— 14,t....,.._..)
<br />Street Number Direction (iti74) -Al Street Name
<br />,...5--s-xl 76c/7
<br />City 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 />(t-li r) ) 61 V7- go aci
<br />APN # LAND USE APPLICATION #
<br />PHONE #2 EXT.
<br />( )
<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR -7 /7 /? CHECK if BILLING ADDRESS
<br />BUSINESS NAME 227/,---F /64 /iiess C:264.2„.,,s-e/#417:1 PHONE,
<br />C-1/C" )
<br />2..s... ,z,..._
<br />CY
<br />-,,..yys__Exr.
<br />HOME or MAILING ADDRESS —
<br />') ,U) e4Sale--11, 4(7F, FAX #
<br />( )
<br />Cm, •-_'. ca=7?67_S i CW ?SOO STATE 241 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 FEDERAL laws.
<br />APPLICANT'S SIGNATURE: e2ri-61--) L-7)(6i e41)1") DATE: ;1)
<br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Er
<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 PAUrty located at the
<br />ssessment aitA i above site address, hereby authorize the release of any and all results, geotechnical data and/or envir M
<br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a t eesalifett'ime it is
<br />provided to me or my representative.
<br />TYPE OF SERVICE REQUESTED: ' V 1 aArA (Auk- aiAla
<br />I , Or
<br />4 2020
<br />COMMENTS:
<br />-PIO 4-4btAkvi.
<br />tip!Al frclIZ IJI/V r ---147.11 0,..LAtp4f4--(247.),
<br />oc ki,416q,44/7.
<br />insUe_, op SWornitd
<br />1114ta nii,
<br />af\
<br />r I , 0 . fr Trctit--Itow 9 Dia3
<br />ACCEPTED BY:ut r---0 LS-' Vi EMPLOYEE #:
<br />q ZO
<br />DATE: 1 /2-0
<br />19,0 ASSIGNED TO: \11-) Qj ST
<br />I
<br />EMPLOYEE #: -3 ...,(p 1 DATE: 1 I
<br />Date Service Completed (if already completed): SERVICE CODE: .'-----,..) PIE: IV) I
<br />Fee Amount- ge 'GO Amount Paid zi a p.,---- Payment Date I [24 '20
<br />Payment Type atuA,,P__, Invoice # ' Check # I 0 tq
<br />Received By: a(.?
<br />EHD 48-02-025
<br />REVISED 11/17/2003
<br />rnalLa 17)0r,son o prQ 677 ,7 4 lo , cery.y? SR FORM (Golden Rod)
<br />NOkkon
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