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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o6710-75 <br /> OVINE OPE OR ^ t (l r� 1 / <br /> 'HECK If BILLING ADDRESS <br /> 1`\ 00 \ <br /> FACILITY NAME (n� <br /> SITEADDRESS • IY�Q-f1 QCC� �� 33-1 <br /> `� � 1 L\Q"�'�Street Name C ZI Cotle <br /> Street Number Directlon <br /> HOME Or IN�G A %ESSS (if if—DDifferent from Site Address) <br /> �ry �Y/L\ITT Sveet Number street Name <br /> CITY STATE ZIP <br /> PHONE#1 ' APN# LAND USE APPLICATION# <br /> ( ) a 2 6 -dol <br /> PHONE#2 Ezr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR1 CHECK if BILLING ADDRESS 0 <br /> vS � <br /> kk �aa `. t <br /> BUSINESS NAME 4C\ 9 1 �6. • I`(� P U �C02 CA <br /> j O I <br /> HOME or MAILING ADDRESS J �, nI, `�O 1 A�A (A%# ) <br /> CITY V IL— STATE 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this ap ti and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA d EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: l <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof Of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> FEB 0 8 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:� EMPLOYEE III: DATE: Q -7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: V - 17 <br /> Date Service Completed (if already completed): SERVICE CODE: o P I E: <br /> Fee Amount: 60 Amount Paid - C9, Payment Date <br /> Payment Type L I� Invoice# Check# / S- Received By: <br /> EHD 48-02-025 I� \� SR FORM(Golden Rod) <br /> 07/17/08 P ytttJJJ"' <br />