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SAN JOAQUIN C iNTY ENVIRONMENTAL HEALTH D, ,ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SR ON U/0 OWNER! OPERATOR-, 4---, trn c/NCtstiV 1-30k-A;\ A 0 LIA ‘ _ CHECK if BILLING ADDRESS FACILITY NAME v-,Flk..7\ 002, 6- d /1 Ara_ S O'hac ...__k_.‘3 SITE ADDRE% . EN 44 C'Wreet Number DiLIon f(a °I, ' Street am Ltdaj - CItv ZIP Code HOME 0 AILING ADDRESS (if Different from Site Address) S.. V 61. (m. grz_ s• 4 u cAci-01,\ /2 5/ cs0 Street Number . CP\ 2 Street Name 1 5 o S CITY STATE 16-1,Y% Cfr ZIP q 5'20 PHONE #1 #1 En. ()9) i l 0 i o) 39- APN # LAND USE APPLICATION # PHONE #2 Err. 24A4 /2 0 9) 'T6 c-i-C q BOS DISTRICT LOCATION CODE --r CONTRACTOR / SERVICE REQUESTOR REQUESTOR Hailfa ejSa "y10 (ra I CHECK If BILLING ADDRESS BUSINESS NAME f-1 /.....)/ 03 C 0 rl /VD _f (-1-trib,f PHONE # (204) q a 1 O r Err -.7.- HOME or MAII-ING ADDRESS / Z .. / 5 6 ha, 1 Rye FAX # ( ) CITY 9/, t kl-v ki sT,T4 ziP /*-4 BILLING ACKNOWLEDGEMENT: ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards - • • P•DERAL laws. APPLICANT'S SIGNATURE. 41A , 1011 DATE: 07 o1 el R / MANAGER 0 OTHER AUTHORIZED AGENT 0 PROPERTY / BUSINESS OWNER If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED: q Ian (*fa- (Mob(' It --kip()) lot:AY/We/sp. COMMENTS: rICCE r IVED JAN 9 c sAN .-- „, 2 2020 , -AQ, J,N tvi ,,,,..fAiviRoN.. co NTAL uNn, "Lrhi oEp ACCEPTED BY: Lautrct • EMPLOYEE #: q 9jo Armet DATE: ASSIGNED TO: \I i CAIY- A EMPLOYEE #: DATE: 12/),./2,0.0 Date Service Completed (if already completed): SERVICE CODE: 5,2..- P E: icie i Fee Amount: J. ,..isc, - 0 k.) Amount PaidI t , ' , ) —I ' ) Payment Date , Payment Type , Invoice # Check # — Received By: , , EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003