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OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS ONNNEREr <br /> DATE: /2 /7 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />REfIC'ENT/ AL- <br />FACILITY ID # SERVICE REQUEST # <br />R 0 ()MU() <br />OWNER/ OPERATOR <br />MR. 7W7 AID ET/ CHECK if ..... BILLING ADDRESS 0 <br />FACILITY NAME <br />SITE ADDRESS 0243 <br />Street Number <br />.F_ <br />Direction <br />isteRTI-c 5T-kgE7 <br />Street Name <br />FRENet4 ex-rip <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />19 6 . Ft)( 349 Street Number Street Name <br />CITY <br />FRENCH eAlvIP <br />STATE ZIP <br />CA f 5.23 I <br />PHONE #1 EXT. <br />(c149 f ) 4-te 1 —0 U° I <br />APN# <br />/13 -/OD-13 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />I <br />LOCATION CODE a ft <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />nu. 7-i,Ny A/ OCE77 CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # EXT. <br />‘91-04 )491-6161 NOC.E_7 I FAR/175 <br />HOME or MAILING ADDRESS <br />117: 0, <br /> <br />Po )( 3 40 <br />FAX # <br />( ) <br />y Crr eikept P ra,EA1C14 <br />STATE eit ZIP cg3( 9 <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 <br />or 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, ST, d FEDERAL laws. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required rifle <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 />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 5,14- 54€ trAS/L/ Ty/Ai/TRATE 4-0AP fit/ 9 -572-/C"/E-, REV/EPAYMehrr <br />COMMENTS: <br />RECEIVEDI <br />DEC 23 2019 <br />8AA, JoAck„A, <br />Etwiliolvm couNry HEALTH Dcp EN TAL <br />ACCEPTED BY: /..;te.111.i EMPLOYEE #: DATE: iiiitAissr <br />ASSIGNED TO:fi- EMPLOYEE <br />9 <br /> #: DATE: (474 T <br />P1 E:,740 0 •"2„.....-- Date Service Completed (if already completed): SERVICE CODE: <br />Fee Amount: EN? v2ty) Amount Paid te to .- . Payment Date <br />Payment Type v60 Invoice # Check # i 2_ 8 0 (p Received By: &Up/ <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003