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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />c 6 <br />FACILITY T # SERVICE REQUEST # <br />TtrU <br />Fs <br />A(pER / OP <br />lC-(k <br />CHECK if <br />OCkfiCI (-)e- 2 <br />BILLING ADDRESS <br />FACILITY NAME v e\ t-Al...A-i 0 7ejo n 3 lc <br />SITE ADDRESS <br />L..) Street Number <br />C <br />Direction Street Name lak r \ CI <br />115,205 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 3(49 Street Number _ ApA\-_4 c(is Ave Street Name <br />CITY <br />a\C)C11-kOrN <br />c STATE ZIP c15,71.15._ <br /> <br />PAONED Err. <br /> <br />(C)kt (1 7 5-- d'°020 <br />APN # LAND USE APPLICATION # <br />PRONE #2 EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />K0 ( <br />, 1 <br />C4 V--08firieZ" CHECK if BILLING ADDRESSWI <br />EXT. <br />_ <br />BUSINESS NAME- <br /> CC) c(; 0 ?eV() rn 3 PV) LI -5---- <br />HOME or MAILINGADDR=SS <br />AM-CVOs Ave <br />FAX # <br />( ) <br />CITY ,cck-4-6,--N CA STATE ZIP 9 <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. <br />APPLICANT'S SIGNATURE: \ <br /> L DATE: 0 / 0 1 / <br />PROPERTY! BUSINESS OWNER ef OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <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 same tirPAy, ed to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: rood 4)10 c/Leck 6117Ay <br />i COMMENTS: MAY <br />0 1 2017 <br />Stivjoitti—lj...i.N. couNry <br />HEALTH m_ENTAL <br />'1"-AttITMEN T <br />ACCEPTED BY: ( \ <br />(9(. l <br />ia EMPLOYEE #: DATE: 5-... / _/ 2 <br />ASSIGNED TO: I I _ [-,i') 1 / r-T-Li 1 1 EMPLOYEE #: DATE: ..../ _ / 7 <br />Date Service Completed/ (if already completed): SERVICE CODE: • ----:!) P/E: ii2(7 i <br />Fee Amount: L i i - 70 il) Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)