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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I tPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />--.A CO2-LkStA \ <br />SERVICE <br />colq3s3 <br />REQUEST # <br />OWNER! OPERATOR <br />51 \ V l c-_ air\ CAN2 2- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME OD <br />'\-°•- \ 1/4000 cOU c i c--) I) ...S -.-"T - ce_ c_re ct.. 611 <br />SE ADDRESS <br />qii- i, (c (9- La- Street Number Direction N ' 6(.116. Street Name SrOGkte City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />(-4 0 1 6 cx- ‘b r\ ec - Street Number Street Name <br />STATE ZIP CIT5t <br />PHONE #1 .....N ...--, <br />(209 Li (-13 — q9 / 4( <br />Exr. APN # LAND USE APPLICATION # <br />PHONE ;#2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /- / <br />1 6 ea_ hcite Z---- CHECK if BILLING ADDRESS <br />BUSINESS NAME a ( n bop() 11 Ci 0 il_S- e -1 Grea i•- <br />-, :A PHONE # <br />(7°?) <br />EXT. <br />93- Ci?/47 <br />HOME Or MAILING ADDRESS, <br />-C) i c,ry Prt. -er c_c't- <br />FAX # <br />( ) <br />CITY _5,-(-D citt-z) v..1 STATE eft- ZIP 9S-cD. o (i <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 ap•lication and tha k to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S AT and FEDERAL <br />DATE: ( g <br />PROPERTY / BUSINESS OWNER El (OPE ATOR I MAN • 4- • OTHER AUTHORIZED AGENT El <br />If APPLICANT is not the EFILLING PARTY proof of authorization to sign is required Title <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: AY/WENT, <br />COMMENTS: eCEIV I <br />ED <br />JUL 12 2 ,018 <br />1141vviliotv41,7 couivry <br />Lrki 1)-p ENZ9 <br />ACCEPTED BY: 4. MAyitylo EMPLOYEE #: DATE: I T <br />ASSIGNED TO: e) . .1.4 11Aiy\..A4 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: 1(je()3 <br />Fee Amount: ' ( 5 00 Amount Paid/5, 0 0 Payment Date - <br />Payment Type ioj& Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08