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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />_ <br />FACILITY ID # SERVICE REQUEST tit <br />C)C7 9 q621/ <br />OWNER! OPERATOR <br />TE-viT, A Frc-r CHECK if BILLING ADDRESS <br />FACILITY NAME <br />:L-0 .rt,-/(1 src <br />SITE ADDRESS / / 0 , <br />Street Number Direction <br />/LTC /-40,11-0 S 13 13. <br />Street Name <br />_c,401/4"-Ii.A.7--c) <br />City <br />'f'/1 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) z,... -7 <br />Street Number <br />7iiili,.-)v- 1/1/4 '1 <br />Street Name <br />CITY (-- A STATE <br />) 1.-/C- PZA/111-11 )st C -4 <br />ZIP 1 <br />PHONE #1 EXT. <br />(c,f/() 7••-? - (-' 0 i q <br />APN # <br />CQ c___ <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( : • (1 /e) ' o ( - -77 '.r- <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />7-:-- , --, g- F-4 r-it CHECK if BILLING ADDRESSO <br />/—ia rt-ft 'S <br />BUSINESS NAME r -- _ .._ <br />FA/11 r),, S j 6 Z <br />PHONE # (ril‘ ) 761 ) - ( I/ I LI <br />EXT. <br />HOME or MAILING ADDRESS _ <br />7 7 /1/41e-(114,--- i4,-4 - I <br />Fax # <br />( ) <br />CITY ci4 ( Itilf,i IL.,.."....t_c) 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 Of <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, STAd F ERAL laws. ID <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at thrtvAi ove <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infgrA <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provide <br />my representative. <br />2018 <br />uN r „ <br />TAL <br />EAT <br />Title <br />TYPE OF SERVICE REQUESTED: fc,cr( ‘2..iii ( 0_1 Ae-- I 7-) --, c --1---/c_v1 4r/G 06 Jo <br />COMMENTS: SAN JOAQu Emmi, hVa kisAm, Ofsmnek <br />"" DePARyi <br />ACCEPTED BY: i.z.,..,„ EMPLOYEE #: DATE: (3 . <br />ASSIGNED TO: k_ - ,... " <br />t.)-1, t rviil <br />EMPLOYEE #: DATE: ‹3 Lo _ ) cd <br />Date Service Completed (if already completed): SERVICE CODE: 0 (47 1 P / E: <br />Fee Amount: \ c.) -) — Amount Par/52 , d 0 Payment Date <br />Payment Type Invoice # C)i‘k #65-44:3_47/675-0e5s— Received By:/// <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)