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SAN JOAQUIN COUNTY ENVIR�REQUE TH DEPARTMENT SERVICAMENDED 08/05/2016 Type of Business or Property FACILITY ID # SERVICE REQUEST # I 7,A C 1 L (•T V,A COa 60-1 z - DATE: OWNER /OPERATOR ILO OI 7(ZA0e L i G �^ l I yl C if BaUNDADmtEss❑ / FACILITY NAME ( 11.,U l —(P— i X L /� L o f,if, vT Le LLLL0- SITE ADDRESS i50 1 Slreei umber 1 I . dreci(on ` Ja- � 1 U� Z'A 0 Stram Name Iz. ) SOA cit ZI Cork HOME Or MAILING ADDRESS (if Different from Site Address) % �� tJ A20 A d— JC) J-014,1 OA -0 [l Street Number I'mal Mama CITY O ( L E— Im STAT ZIP '3-7 9 C),, t Ex ' PHONE 01 //� ( U/ I � � l b AEN # LAND USE APPLICATION # PHONE �#` 1L4 E1* BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /y C Rou� ( n/t , avell.. l.' CHECK If 81LlANG ADDRESS® BUSINESS NAME �' „ `„� rC- ti t ei- r z l PHONE# HOME or MAILING ADDRESS ^ST;' l� C,40G DATE: (A%�) ,t om®0/3Z-7[500 L� /LUCAS CITY ancien a 0Li r 'C'o(J6A STATE /� A ZIP BILLING ACKNOWIXTIGEMENI': 1, 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. 1 also certify that I have prepared • application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinmme Codes'Sr." ar , STATE aid FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 08/05/2016 PROPERTY/ BUSINESS OWNER OPERATOR/MAN GER ❑ OTHER AUTHORIZED AGLNT4::2 JIr�^vlti /c _ IfAPPLICANT is nor ie BILLINGPARTI',roof ofauthorization to sign is required Title AUTHORIZATION TO RELEASE INPORhIATION: 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: ,(�. COMMENTS:i^ 1 A 0 v, 's # i &'�� , 7 L/�f eLLF- vJ� ld wt.c v e.4e. cL 64C'Q'A bvv l T21L.L,-1 S Fitt l i�jUt- k 6� Repair Vapor Penetration ' on UDC 14/15 rC- ti t ei- r z l ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 49-02-025 SR FORM (Golden Rod) REVISED 11117/2003 Au c, i vat",'r PC E