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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY <br />e'll-CO-D--)0 <br />ID # SERVICE REQUEST # <br />St( 0674b) 1 <br />OWNER / OPERATOR AA 4f, i 0 f,-- r --c-‹ R et 0 .-e t CHECK if BILLING ADDRESS <br />FACILITY NAME SA r) m oc 17 c o c <br />SITE ADDRESS <br />1111 Street Number Direction ik. 0160 -r--. Street Name <br />-5i-pc-k--Joil <br />City <br />9 5--Q0(c, <br />Zip Cnirli. <br />HOME MAILING ADDRESS (If Different from Site Address) <br />"D. Street N mber <br />,..D IA) '---- Street Name <br />,; ' Y k STATE ZIP Q Scao(c, <br />PHONE #1 Err. <br />(7-C14)?lag .- <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext <br />( ) .L---- <br />BOS DISTRICT LOCATION CODE <br />C NTRACTOR / SERVICE RE UESTOR <br />REQUESTOR A <br />NIckurb P-eiu_z_ Rc . ci_ef CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME <br />ThOt 1/1 MCA CC Of <br />PHONE # <br />( 70i) 3(-)ciS"" 2 3T io2_ <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />Cirt .-i-cr.k.47, <br />n <br />STATE c4,3 ZIP 9 <br />, <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 laws. <br />APPLICANT'S SIGNATURE: M a-v rc 17)(' < (/cf DATE: <br />PROPERTY / BUSINESS OWNEllit. 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 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: v----coct q Oil I G i e_ )/6pe ChCii <br />PAYMENT <br />COMMENTS: <br />owner MAR I) I 2016 <br />SAN ...10,4OUN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:%. izci crt EMPLOYEE #: DATE: 5 _0/ _ / 62, <br />ASSIGNED TO: 13 \ 5,5 1 (II EMPLOYEE #: DATE: 3 _0/ <br />Date Service Completed (if already completed): SERVICE CODE: C, Co i P/E: <br />Fee Amount: 1".0---- Amount Paid /3 c), (p c) i Payment Date <br />Payment Type C, 01 S ). Invoice # Check # Received By: T7 / <br />Title <br />EHD 48-02-025 <br />0 7/17/08 <br />SR FORM (Golden Rod)