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SAN JOAQUira COUNTY ENVIRONMENTAL HEALTH L...PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />I ,,,,,,:k.), CHECK if BILLING ADDRESS <br />FACILITY NAME r— ere'k F-1- cc % # 5 CS c --9-3 <br />SITE ADDRESS 15 55 <br />Street Number Direction i-)ec c) s tkr <br />Street Name StocA-1--orm <br />City <br />(-452oci <br />Zip Code <br />HOME or MAILING ADDVSS (If Different from Site Address) <br />I.- 5j T,,, ,0) rs, Street Number Street Name <br />CITY STATE ZIP A-Lo <br />PHONE #1 <br />(XI ) 62 2- — CPAYr <br />ExT. APN # <br />OM--A ( ODL(C1 <br />I LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. II <br />II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR! SERVICE RE UESTOR <br />REQUESTOR i , <br />Ci i rri 1 11 born nf-V-1 CHECK if BILLING ADDRESS Rf <br />BUSINESS NAME PHONE # <br />( an (.02-5— (.08n7 <br />EXT. <br />HOME or MAILING ADDRESS 6 r_e Ed oDs 1: 5 CSc-7-5 3 <br />FAX # <br />( ) <br />CITY ce 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 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 /> <br />fA <br />PROPERTY / BUSINESS OWNEF4( OPER OR / MANAGER El OTHER AUTHORIZED AGENT El <br />If APPLICANT /s not the BILLING PARTY, proof of authorization to sign is required 7'itle <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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: PAYMENT <br />COMMENTS: RECEIVED <br />APR 2 6 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: N E: <br />Fee Amount: Amount Paid 41 2 Payment (40 Date q \ 2 ce i <br />Payment Type r 1,1 Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: DATE: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)