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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />— <br />s RERyicE REA‘.17:71#n <br />'.1 ( <br />OWNER / OPERATOR <br />leJ <br />_.,-- <br />c: C (4- VI C. Z. <br />CHECK if BILLING ADDRESS <br />_. <br />FACILITY NAME L fa-u -te\ric) 0 Li vvc_a ' <br />SITE ADDRESS <br />I 1— 1 -1-- Street Number Direction <br />I , <br />U In 1 0 Yi _c4 Street Name <br />sic c AToA: <br />City <br />6/ S 2— ('%( <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different <br />5 i h* <br />from <br />k S 1- <br />Site Address) <br />Street Number <br />i <br />Street Name .5.__ 1 A c K <br />STATE ZIP <br />0_ >q • <br /> <br />q .2— <br />CITY <br />C VO C k A-0 0 <br />PHONE #1 EXT. <br />(?-oCi) (gg -g75 g <br />APN # LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />e T firo 11i71-e z CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />S avyi,( PHONE # ( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY 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 Of <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, STA and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br /> <br />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: <br />PAYA4EN COMMENTS: r <br />RECEiVED <br />NOV 0 2 2018 <br />SAN joAQuiN civo.rAuNiy <br />ENVIRONM HE,4 <br />ACCEPTED BY: \._. 0i Ar 1 ,...Scaef'S EMPLOYEE #: LPAWEIT ,f -se <br />ASSIGNED TO: k ea. iti ra L. EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 00 P / El& C3 <br />Fee Amount 60 Amount Paid / C Payment Date ! i / - <br />• <br />7 i i <br />Payment Type 4 JA _ Invoice # Check # Received By: / <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)