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SAN JOAQUivi COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SyzCD-1IL�Z\ <br /> OWNER/OPERATOR <br /> � ^ L' '0�k,n^`"�^`<-, CHECK If BILLING ADDRESS <br /> FACILITY NAME -/A (fi `7 n lc-o,Y r v <br /> SITE ADDRESS 7 �a R I Cq IlfilY--1(A 5� S�riG<<fGN �l SZO 3 <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1 �) e'_"J L'I/ i I C O w Ct A VStreet Number Street Name <br /> CITY STATE ZIP <br /> S-tc c i, Iz �i C A '/S- ;- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (1C;q ) 5--/ 3 - U <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Lj I � 1��,r( V ��� �-•y � CHECK If BILLING ADDRESS <br /> BUSINESS NAME j' l �CP # EXT. <br /> Leo <br /> HOME or MAILING ADDRESS FAX# <br /> n WCt �y ( ) <br /> CITY Gi ,^ STATE L ZIP S Zv <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 /> 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. l <br /> APPLICANT'S SIGNATURE: Lois F—V)rI �i✓P L tokm Ct-S DATE: 71-70 116 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7'irl c <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sameprovided to me or <br /> my representative. ®pPAYM04tr <br /> IR <br /> TYPE OF SERVICE REQUESTED: GCE <br /> COMMENTS: JUL <br /> r1 0 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 8r-AL.TH DEPARTMENT <br /> ACCEPTED BY: 1� 60 <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: rn EMPLOYEE#: DATE: <br /> Date Service Completed (if already Comp ete SERVICE CODE: C W PIE: I <br /> Fee Amount: 10IC�2 00 1 Amount Paid Payment Date -7 2b ( � V <br /> Payment Type ce�A T,nvoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />