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SAN JOAQU'OUNTY ENVIRONMENTAL HEALTh _ ZPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # \. OWNER / OPERATOR /) _ A ii) 14 oY c tv\A-cq A E CHECK if BILLING ADDRESS FACILITY NAME --- i 4c c) S 1-c4 F i,t_ ttNATT LS SITE ADDRESS 2C! 0 a Street Number Direction E Stre8lame City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 9 0 II q 5 it Pi ''SC L/ t2? I i i v 0 Y Street Number Street Name CITY STATE 7/ , A ZIP S 1- O C V1-614 (1 ,CA ci 5 Z1 a PHONE #1 Exr. ( l ) 67'3 7-- CI -''' APN # LAND USE APPLICATION # PHONE #2 EXT. (fC4 ) 9 6. 3 -Y7-/O BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR kg ,, WO a \'\ -V M\INNZ:V l,-- CHECK if BILLING ADDRESS BUSINESS NAME . nrk C 0 S I-- C-6 -E-- ----- PHONE # (i1C1) Z-6 i - Exr HOME or MAILING ADDRESS 11°41 Pt 1/1 c)11 Ci/Tt t FAX # ( ) CITY (A/1_ STATE LAA- ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:&" AO Yo 1lAl2-T/4 DATE: PROPERTY! BUSINESS OWNE OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 1.1. APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Pill)" COMMENTS: it e ivr ovp„ Nov 0 , -4-, '944,,10 1 2019 AQUIA, tit 7. ib0041/14 COL/A, II DP/1)41117;44 7' DATE: ACCEPTED BY: ..je 60 EMPLOYEE #: C-kS"'"2_ ASSIGNED TO: TO: IX( ,e ..., jec\ 0 EMPLOYEE #: C7\--3-2_ DATE: \\\ \ \ \C\ Date Service Completed (if already completed): SERVICE CODE: _P I E: -„ . (()Amount Fee Amount: N \-2 'd) Paicf ' _ ,,,, Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003