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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />4---6()J -cc,. uc, K <br />FACILITY ID # <br />rki/tA) <br />SERVICE REQUEST # gtz.00 -1 -72,12 <br />OWNER / OPERATOR <br />. . -3- , I V Akile--C2-6 CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ApDPFcc I <br />Street Number 4-1 1 irection <br />-21- 1 ()J in <br />, <br />Street Name <br />'-')' A C .414 11/Le il f ".° <br />City <br />q 1 1 <br />ZIP Code <br />HOMED!' MAILING ADDRESS (If Different from Site Address) 13 ai , <br />L2 i2, C-(n b P-(2- Street Number <br />6 k Drya c.: -.- <br />Street Name <br />CITY /) 1 1 .iit..1.:1E Zip .-7 <br />I\ --C__ <br />PHONE #1 EXT. <br />(/4 ) , <br />APN # LAND USE APPLICATION # <br />PHONE #2 • \ EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , <br />/114140"a-0 <br />CHECK if BILLING ADDRESS <br />NAME ,- <br />L1 <br />v.c <br /> E <br />XT.BUSINESS -7 Cr <br /> <br />HOME or MAILING ADDRESS <br />C)Q (Li' L ))P% 0— U <br />FAX # <br />( ) <br />Crry ./2_0 et A ( ./2 STATEr, , ZIP 7 y 7 <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, STATE nd FEDERAL laws. <br /> <br />DATE: <br />PROPERTY! BUSINESS OWNER V OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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: Faxl. Veit( Lte- `'t lo (24k91 <br />COMMENTS: 1 i 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:r EMPLOYEE #: DATE: Altig me,varofft <br />ASSIGNED TO: , <br />j7 <br />O icire,(If vvon EMPLOYEE #: DATE: L.1 il ,ill <br />Date Service Completed (if s-already compleied): SERVICE CODE: 06 1 PIE: 1(0 0'5 <br />Fee Amount: 3 1 1 Amount Paid 1 3 9 • e 0 Payment Date ( b -3 / i'7 <br />Payment Type Invoice # ctirM 0 s- ?N. 7 s ,) Received By: ,7 _ <br />APPLICANT'S SIGNATURE: ao <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08