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E <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />MAY 0 5 2016 <br />Type of Business or Property <br />FACILITY ID # <br />+ O�d�do12 <br />SERVICE <br />;9W7Lt <br />OWNER IVOAF� <br />o, <br />\jzA C6,Aaif, LL -0--7 <br />CHECK if BILLING ADDRESS <br />pppp <br />FACILITY NAME VJO <br />d� <br />EMPLOYEE #: <br />SITE ADDRESS <br />Street Number <br />D rf ebtton <br />�` y <br />`Stf t me <br />i E: <br />C <br />n*1 de <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />LawetName <br />Lo <br />invoice # Ch # <br />CITY <br />STAT t <br />ZIP <br />P NE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 <br />ExT, <br />(41�4 <br />BOS DISTRICT <br />LOCATION CODE <br />W041211111 11PYTIM 11 DU 1191 <br />l'ZEvl41'ESF #`e:.:'_ <br />REQUESTOR "� CHECK If BILLING ADDRESS 13 <br />an <br />BUSINESS NAME <br />PHONE# Exr. <br />HOME or MAILING ADDRESS j a <br />j <br />FAX# <br />( 1 <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or auttiortzea agent or same, .. <br />.... ...... ___._—acknOtiYled that_alLSite—Bnd/Q pivje,c S cifmI ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project^_ <br />or activity will be billed to me or my bus' ss as ide tified on this form. <br />I also. certify that I have prepared thi applieati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes; Stand ds, TAT and FED <br />APPLICANT'S SIGNATURE: DATE: t <br />PROPERTY /BUSINESS OR'NER❑ ERAT ANACER ® OTHER AUTHORIZED AGENT <br />_ <br />If APPL/CANT is not the BILLING PARTY, proof Of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment . <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is,, <br />rovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: fJ _ t C 4 l a (�66 d 9+ P� ' S "o Q <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DAT4E:5 <br />ASSIGNED TO: �/`lJrnn am <br />EMPLOYEE #: <br />DAT( (� <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ! <br />i E: <br />Fee Amount: <br />Amount Pal S .()6 <br />Payment Date s �' <br />Payment Type V % <br />invoice # Ch # <br />d `t 77 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Al <br />�i <br />SR FORM (Golden Rod) � . <br />41 <br />N ��AK <br />