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OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />'of r re— DATE: APPLICANT'S SIGNATURE: <br />PROPERTY/BUSINESS OWNEREr <br />SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH I ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />_ <br />FACILITY ID # SERVICE REQUEST # <br />s :: <br />OWNER! OPERATOR / <br />CHECK if <br />0 I i : r ( o l € -I (Piiwi e Al-f re-k <br />BILLING ADDRESS <br />FACILITY NAME u , i , <br />n <br />SITE ADDRESS <br />17 1 7 Street Number Direction Street Name <br />Um 0 ti 3+ <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Sit Address) <br />6 r104-. 'Jr) nAc, r A Street Number ,2,,aQct Street Name <br />CITY STATE <br />C-5c,a1 or) 6- A <br />ZIP <br />C1 5 3;0 <br />PHONE #1 Err. <br />( .96' <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />i REQUESTOR <br />rt <br />P 1' <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME ,- PHONE # EXT. <br />HOME or MAILING ADDReSS <br />gOI () E <br />FAX # <br />Cry Q___ STATEt bit::. ZIP q53„20 <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 FEDERAL laws. <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. <br />TYPE OF SERVICE REQUESTED: P( 04 If 4-00S Ct VIS1,1 101161 <br />irl r <br />RECE.41E.47. <br />COMMENTS: <br />OLW <br />/ lie 0 <br />f-1,, <br />I 1- 11 <br />2019 <br /> i A.. <br />- <br />:1A0 <br />L <br />A Q ii <br /> <br />IyaVVIRON /N CouN <br />1.71.1 DEP114Ai rA1.7)' ARTAisAir <br />BY: <br />k <br />ACCEPTED AvtrA EMPLOYEE #: (4 0 DATE: f <br />ASSIGNED TO: <br />IQ olta, if) li-- <br />EMPLOYEE #: DATE: / 212.. 9 Ilq <br />Date Service Completed (if already completed): SERVICE CODE: C c, i PIE. I 09 <br />Fee Amoun : <br />1 ()'. (,d <br />Amount Paid Payment Date , i <br />Payment Type Invoice # Check # Received By: i <br />/ <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003