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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R CSb7_ /{ <br /> OWNER OPERATOR AV )t-) Le;:�L`C—' <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> S� <br /> SITEArDDRESS �C� <br /> 7/ Slreet Nu-ber Dir¢dion ��0� Sheer Nam CI ZJin COL <br /> HOME DDC s (if Differegt fr Site Address) <br /> Ekcp Street Number <br /> CITY I ` STATE 14V 71 , ^ <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# {J"-`h/L� <br /> 261 <br /> PHONE#2 T BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST OR c 1 <br /> UtD CS�.J E- CHECK If BILLING ADDIE1S <br /> BUSINESS NAME PIj NE# <br /> —1 +7 <br /> terf /+ 7 -153"l <br /> HOME or MAILwo AJDRES3 ' �`� (A%# ) ^ <br /> I _ - * ` STATECA 7.IP <br /> BILLING ACKNOWLEDGEMIENT: 1, t;-,e 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 tome nr.my busine- as idei, Ified on this form. <br /> I also certif; tha' I have prepared this a pI cation and tY.-.t the wor t DZerformed will be done in nccc,rdarce with all SAN JOAQUIN <br /> C )LINTY Oranance Codes,Standards, S T and FED R <br /> C- <br /> t <br /> APPLICAN F'S SIGNATURE: DATE:�U t?✓ 5 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ A1A'• <br /> If APPLICANT is not L!e 31LLING PARTY proof of authorization to sign is required iue <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby autholize 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 ,s provided to I'ne Of <br /> ny representative. <br /> FYIES�RITGE REQDESTEDI <br /> COMMENT <br /> I <br /> ACCEPTED Bl EMPLOYEE#: DATE:i m15!- f —� <br /> AsSICNED TO: M N(S(�(/✓) EMPLOYEE#: DATE: �-1-' t 1rs <br /> Date Service Cninpleted (if already completed): SERVICE CODE: ,SGo� � PIE: 1Q.,03i <br /> Fee Amount: Amount Paid 1_ b. Payment Date ,D ` Z (`S <br /> Payment Type ; Invoice# Check# PAYMENT Receiv d By: <br /> EHD 48-02-025 OCT 1 2 2015 SR FORM(Golden Rod) <br /> 07117/08 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br />