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SAN JOAQI. :MINTY ENVIRONMENTAL HEAL IEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />' ‘....A.MCin Via.cA0 t--1 <br />FACILITY ID # <br />Fi ,ttL2‘ - <br />SERVICE REQUEST # <br />t 5 Q. 001 qlq Cl <br />OWNER / OPERATOR <br />CHECK if <br />PNC.L.nr-1 C) r Ewe r re iro <br />BILLING ADDRESS 1113 <br />Fawn' NAME <br />E\ eiv-u 1 \ -cost --JE <br />,SITE ADDRESS 1 -6 -6 1 <br />Street Number <br />C • <br />Direction <br />IN k 1 ,S 0 r" lrvcA--,3 <br />Street Name <br />l'Ot.-V----ton <br />Cite <br />c152.D5 <br />Zia Cede <br />HOME or MAILING ADDRESS (If Different from Site Address) V3 27 1 <br />Street Number <br />S • k.N) i \ (j0{-1 WA/‘.4 <br />Street Name <br />CITY 3 STATE 0; ZIP <br />CA5 2-0S <br />PHOSE #1 EXT. <br />( 109 ) 2 Lt -2- - 2O \C\ <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />SOS DISTRICT/ LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />Fan-10 tTh 60e rf 'e ru,- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # Err. <br />( 2.-cci ) 2-L12 — 20\q <br />HOME Or MAILING ADDRESS <br />13 2)1 S. Vvi tsar, wo-i <br />Fax # <br />( ) <br />-Crrt STATE <br />CFI- • <br />ZIP GI sz 0 5 <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 />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 I EDERI. ws_ <br />APPLICANT'S SIGNATURE: <br />Paonan / BUSINESS 0%% N ERIS) <br />DATE: <br />OPERATOR/ MANAGER 0 <br />OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARIY, proof of authorization to sign is required <br /> <br />, <br /> <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 same same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Tr" Syec <br /> -I <br />COMMENTS: <br />OCt 2 , <br />Silk 4 2018 <br />//4 <br />— ,10/4Qu <br />4111/ROA/A1 COO l. Ty 0,._4447;4 piry <br />i-',i/s)rwl--Nr <br />ACCEPTED BY: ,\I . N\ Ovve 0 EMPLOYEE #: DATE: <br />ASSIGNED TO: \..._ . 4 u s..) A EMPLOYEE #: DATE: I 0,7_61_1g <br />Date Service Completed (if already completed): SERVICE CODE: Okp t Pi E: <br />Fee Amount: 4,, Amount Pa •-t 15-a?. p - Payment Date 10A-f IF - <br />Payment Type CIL , Invoice # Check # 2_3'6, y. T Received By: ki2)1 <br />Troi,ve 4V 5 SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003