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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />WA) <br />SERVICE REQUEST !! <br />size 0-74 tbi <br />OWNER I OPERATOR <br />11/6" 1,--.:: <br />/._. CHECK if BILLING ADDRESS <br />re77 (70 v"-7 (-) 2 <br />_pi/TY NAME ./ on pe 0 cf /,-; <br />SITE ADDRESS <br />/235- Street Number Direction Pe r i y f91/( Street Name ch r City ( .7 9 Zip <br />CD <br />HOME Or MAILIN ADDRESS (If Different from Site Address) <br />1 2-35- e 11)/ V, Street Number <br />p <br />Street Name <br />CITY STATE ZIP <br />, <br />(7. <br />(---' 9-5-2,3 <br />PHONE #1 Ext. <br />(2,9) //57` -2 7/ 3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />2 <br />REQUESTOR c____ r.N • CHECK if BILLING ADDRESS <br />BUSINESS NAME , <br />-' i (///;:;1 /II 71G f)/7 .) OL C e 4 --7,7 P e c., 0 vii: <br />PHONE # <br />(Z--`1) 1..5."-/ - 7 ?) 3 <br />EXT. <br />HOME or MAILAio ADDRESS <br />)23-5— f } e if / Y , 4, e <br />FAX!! <br />( ) <br />CITY h,(„/7‘,„.7 STATE ZIP <br />?52c' 3 <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 ST TE and FEDERAL Jaws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY! BUSINESS OWNER 0 dPERATOR / 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: ti9 2f Veihja6 ,Tkpet4-01 PAYMENT <br />COMMENTS: RECEIVED <br />MAY 1 3 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEAI I II DEPARTMENT <br />ACCEPTED BY: <br />A <br />EMPLOYEE #: DATE: 5113/1 (0 <br />TO: <br />IA/M9 <br />ASSIGNED EMPLOYEE #: DATE: S7r5/1 sp <br />Date Service Completed (if aleaady completed): SERVICE CODE: 5Call I <br />PIE: hays <br />Fee Amount: A ( 1)'40131 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08