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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />F A00632(1 <br />SERVIC,E REQUEST # s2000, 1 (0 <br />OWNER! OPERATOR <br />t/mc? _fre, epy/ c,)k/c//c7'. r c--a m 0 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />lie 0 q / <br />SITE ADDRESS <br />3 5c) 0 Street Number 1V1 Direction V/ i IS ° Y) Street Name 5 I-C 110° i7 q5 '() Zip Code 5- <br />HOME or MAILING ADDRESS (If Different from Site Address) 3n2- ree umber Hi .5) 0 qie U/4S Street Name <br />/ STATE A CITY <br />P111519. CA}- <br />ZIP 6_ <br />PHONE #1 Exi. <br />(/25T 70 7q7 ,-( <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ) <br />z_-_ 1 Pi 4 A/61 (171i ox c.c-i/ G q 11 o Yc 0 CHECK if BILLING ADDRESS El <br />BUSINESS NAME Z--/ Ctie -1- Z0 /1'16" <br />PHO NE # <br />ens) V i779zi <br />EXT. <br />HOME or MAILING ADDRESS <br />3?32 //)5/2ale (A/C,ky <br />FAX # <br />( ) <br />CITY pil-f> i)tiri STATE ZIP <br />BILLING ACKNOWLEDGEMENT: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: <br />PROPERTY / BUSINESS OWNER'' OPERATOR / A GER El OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING 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 <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessm <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi <br />my representative. <br />TYPE OF SERVICE REQUESTED: CIIDAS lit t 1 NV) % C ofrii„.7.. /04.10Q <br />49 COMMENTS: <br />l'ic 44 <br />CANIkay P4/0.4-44 4- *41. <br />ACCEPTED BY: LA ca . EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />1L(911, <br />EMPLOYEE #: DATE: lo_ia,0 7 i <br />PIE: /L00...., <br />/5 <br />Date Service Completed (if already completed): SERVICE CODE: 0 (0 I <br />Fee Amount4 1f5 /2 • GU Amount Paid Payment Date /2.60 <br />Payment Type -1a4 Invoice # Check # Receiv d By: <br />DATE: 12— zo—ig" <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08