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APPLICANT'S SIGNATURE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />,1-7/1/2__Pdk <br />FACILITY ID # <br />Fhp( SERVICE REQUEST # .. <br />-112o0i 70-140 <br />OWNER! OPERATOR <br />--E./-714) A bil a /-1 6/P-41S (-Leβ€” <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Mild i_.5 f'i2.41_5 (Cc <br />SITE ADDRESS <br />if 6---C 0 - Stre Number Direction 4I'VY 2 4 Street Name <br />< t4rel ki <br />City <br />c), / ( <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />6 14 1 g Street Number MC) 2 /11,1)A0 ;.k β€” reet na me <br />CITY STATE STATE , ZIP <br />C A, -,, c--2_ / <br />PHONE #1 , Ex-r. <br />(21) .../ APN 4 LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />13.BNESTOR <br />( ( t-- AtV2.0 -NOT-A <br />CHECK if BILLING ADDRESS <br />Byg*SS_Nia,ME <br />ZVA 0/ --A ,./-449-4,V, 41:_e <br />PHONE # <br />E3 11 ) if)t '0 --. ') L/ <br />EXT. <br />"c <br />HOME or MAILING ADDRESS <br />/lac e. <br />FAX # <br />CITY 5re.,,oiern) <br />ritTE ZIP 41s,--- / <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 FEDERAL laws. <br />DATE: fr (-2^ 7 3 <br />PROPERTY/ BUSINESS OWNER O OPERATOR / MANAGER la 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 <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: <br />1.-if-kk I WI 'CIA; I <br />RECENED <br />COMMENTS: <br />JAN 1 2 :_1Y23 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />1-IEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: (..._ β€” ___ 2_ 40 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: (pc, ( P / E: icio 2_ <br />Fee Amount: 1 5-,,=)0 Amount Paid ts- Payment Date t(/ '212-0 "2 <br />Payment Type visit. Invoice # Clieck # i ___, s-- , _.i ,, -"-2,c, Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003