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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />eo mmF,(4 c /4-t, <br />FACILITY ID # SERVICE REQUEST # <br />912M ih-19t W) <br />OWNER/OPERATOR &-.--?r . c 1 f 6/Vet< &ly CHECK if <br />e 4 A4---/Iic&-- 6 /V-62-.01,0 (-4473014,47-V, C/r9 11011 Cl/14/V <br />BILLING ADDRESS El <br />FACILITY NAME <br />S i711= goo 4,4pvie/ve - z-/r~Aec /5243 0 A- 7-C.,A) <br />SITE ADDRESS <br />/5'7'9? Street Number <br />IA/ <br />Direction <br />C (--274-fi-4- /-7401-4.-,, w ge,4,o <br />Street Name <br />772-4e--7 <br />City <br />C3 '7? <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 Err. <br />(92 5 ) 1/2 2 — // c3_-/ <br />APN # I <br />26/ — NO —0 -5 . <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT <br />CT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />'--/"" P/1) 5-1,k 0 4..? <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br /> AV/e-i6VIV- 7--- C/0 4- &/\/& (/'-'r-1---4-S" <br />PHONE # <br />((1 25 ) 21/5-- 87 99 <br />EXT. <br />HOME or MAILING ADDRESS <br />Z5 (2 C-ti7k.,e 7 4A1 • <br />FAX # <br />( ) <br />1 CITY <br />/114 -t-- C rq <br />STATE <br />Cs` 4 <br />ZIP <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, STATE and FEDE aws. <br /> <br />DATE: /2 -3---2 ' <br /> <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER0 <br /> <br />OTHER AUTHORIZED AGENT Er e /1/ / EA/6. //,&--6.2 <br /> <br />OPERATOR / MANAGER 0 <br /> <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 <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 />C, heCk <br />N 3-11111 1111111=11111 V <br />TYPE OF SERVICE REQUESTED: bi johpo ieci sy571-eyvi pi,, v, RECEIVED <br />COMMENTS: <- le ?7O— sy5tekv, 4zo i LI/ /9 p --/ ./i- .5 744 ki Ciatal< <br />DEC 0 9 2020 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />EMPLOYEE #: DATE: ACCEPTED BY: ,...,.......---„,"""...-------- <br />ASSIGNED TO: ill k EMPLOYEE #: DATE: 0/0 3,ho a 0 <br />Date Service Completed (if already completed): SERVICE CODE: (..-0Z ._ PIE: I-0 0 / <br />Fee Amount: :_z, • ' Amount Paid i 3 0,4 Payment Date <br />Payment Type Invoice # Chen(% 4t 1 ( -7 0 2.7 cli Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003