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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L'EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />[ <br />SERVICE REQUEST # <br />- <br />-7\1-- LIti I U( k.) 1 <br />---. • <br />P-1 <br />, I, <br />OWNER! OPERATin . , <br />LA1)(02/ Kuro CHECK if BILLING ADDRESS <br />FACILITY NAME <br />OAS ) Sat ( kis <br />SITE ADDRESS MOO <br />Street Number Direction <br /> <br />-\Grir\-ex \-\enr\I c,T <br />Street Name I --\--foc,\I City c.A <br />,ip Code <br />HOME Or/AILING ADDRESS (If Different from Site Address) <br />000 *Me/ do-7 ry C 7- Street Number Street Name <br />CITY <br />Tr or( v <br />STATE ZIP cr -7 q_53 -7V <br />PHONE #1 <br />2o9) 621 c705(0 <br />EXT. APN # LAND USE APPLICATION # <br />F 5, AN23to a 15 EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR A //f7(/J/(CHECK k - ciJo.i if BILLING ADDRESS <br />BUSINESS NAME gosas' an <br />EXT. <br />ock3 pm#) 50 2. 5, )5 <br />HOME or MAILING ADDRESS 2_000 -\--stan-es- )k-,e-rvi•-1 Cr <br />FAX # <br />( ) <br />CITY <br />-73C <br />S-64 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 />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 lawA. <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <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 time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: PAYMENT <br />COMMENTS: <br />SAN <br />SEP <br />ENVIRONMENTAL HEALTDHATECEPtrytLq <br />RECEIVED <br />20 2018 <br />JOAQUIN COUNTY <br />DATE: <br />ACCEPTED BY: q .0A,1PQiin, 0 <br />EMPLOYEE #: <br />ASSIGNED TO: v... untfillac, EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: 0(..t2 ( P / E: 1 in.y3 <br />Fee Amount: 2 — Amount Paid „:‘ 52 Payment Date 1, ( \ 'i .-2_0 <br />Payment Type ( Invoice # Check # 0 4 Received By: -2tiSil <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08