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I also certify that I have prepared this application and that the <br />COUNTY Ordinance Codes, Standards, S <br />APPLICANT'S SIGNATUR <br />ork to be performed will be done in accordance with all SAN JOAQUIN <br />DATE: r6 -10 -2_0 <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El <br />SAN JOAQL COUNTY ENVIRONMENTAL HEAL141A)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />,lavny 6- &WIT- CHECK if BILLING ADDRESS <br />FACILITY NAMES clpioi --(3 uifvli 1.4)\-- ,.....c6- <br />SITE ADDRESS <br />I -7)) tA"fi cr. S Direction <br />0 m c N STY2-frr <br />Street Name <br />5tc (VT41.1 <br />City 95-2-6 (0 ip Code <br />HOME or MAILING ADDO ESS (If Different from Site Address) <br />59 3 <br />t <br />e.---14A-f Street Number 1 Ai,' k c Street Name <br />STATEck ZIP 9,, s,-z, 7 <br />CITY51-4. <br />PHONE #1 EXT. <br />(5 ) tO3 li ? ? <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUUTOR <br />7 (N/C3A-1 E - 6 a-A.0,-r CHECK if BILLING ADDRESS <br />BUSINm)N AVI <br />1 <br />I EA cm_ .,--- PHONE ,_, <br />( L-v <br />k <br />0 _? , <br />7 ._51 , 7 i EXT. <br />HOME or MAILING ADDRESS <br />/ 2.6 2.— to4 , L_ M/-' LE-1,-) Fax # <br />( ) <br />CITY jiacv....7-..c_i_.... tit STATE ZIWI/Tv, 7 <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 <br />or activity will be billed to me or my business as identified on this form. <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. DAVMENT <br />TYPE OF SERVICE REQUESTED: Tc="0 Oc._ \i -e\C<\ c„\--e_ <br />F /—• - - <br />-K__\(-Nc.,v-e c-t- \ o\r"\ RECEIVED <br />COMMENTS: <br />MAR 1 3 2020 <br />. SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: C„....:\ . NOC\ 0,\.\( \ \ \C\..12:1_ EMPLOYEE #: DATE: ••••\ <br />ASSIGNED TO: c. 9_cmy-,‘ \• ,c e --L EMPLOYEE #: DATE: -3 \ \ -&\ ...2_0 <br />Date Service Completed (if already completed): SERVICE CODE: \ P7: \'o -s <br />Fee Amount: c\AC:3-2._ "..) Amount Paid * ( g 2_ — Payment Date '), <br />Payment Type ' Invoice # CtretV# t(..) it -1., 0 2,, -2_ Received By:44,-7 <br />END 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003