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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Fl o -1,8Q) 0 o 4( <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />tC-I n I ‘e-(--\ Totc_kc CHECK if BILLING ADDRESS <br />FACILITY NAME --->„ , <br />DO Ci-) ' s OM <br />SITE ADDRESS - <br />9,6 6, tcy- Street Number Direction -7- 1--- u tk)C--- '5 Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I Zo 2 vvI vvizu. I ew,i>ie Street Number Street Name <br />CITY C STATE ZIP <br />- , C,, CI r-2_ t C) <br />PHONE #1 EXT. APN # <br />7-a209 —9- <br />LAND USE APPLICATION # <br />(a ) 5 1— C rq 2 k <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ( CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME PHONE # <br />55'2 Y <br />EXT. <br />HOME or MAILING ADDRESS <br />[ 2. 0 Z__ 5u pv-, v-,-16_.- e._u /&__-'i D Z <br />FAX # <br />( ) <br />CITY 7)A-C)CA( i-i, Vl C.-_C-- nc-7 /6 <br />STATE ZIP <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 OE <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this applcation-aQd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards ATE and FEDE <br />APPLICANT'S SIGNATURE: <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 tirpUtiger ided to me Of <br />my representative. PAY <br />TYPE OF OF SERVICE REQUESTED: <br />COMMENTS: juN 0% 2018 <br />ETY S"ANEAENJ:v°1:"AREQu :°DENIPt4wIAREIT.TUMALNINT I <br />ACCEPTED BY: EMPLOYEE #: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/E: <br />Fee Amount: Amount Paid - <br />Payment Date 6 / c.,?/ t S( <br />Payment Type D e i 1 <br />09 . ' <br />Invoice # Check # ---- Received By: <br />_ <br />DATE: (57/571 <br />PROPERTY / BUSINESS OWNERk OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />Title <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08