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r' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # COMMENTS: > D T c TO l%c-F-If 7N -C- THS W&:9'i L L( L 7-H 6 I ACCEPTED BY: OWNER I OPERATOR J CHECK If BILLING ADDRESS r n l 0.h+` FACILITY NAME SITE ADDRESS BUSINESS NAME P oc c\ PIE: Fee Amount: ° Street Number Direction Payment Date Street Name c1tv Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Check # k -Lw HOME or MAILING ADDRESS omc Lo `'. FAX # Street Number Street Name I Tt STATE ZIP `�S3Zv Sc�\or-\ PHONE #1 EXT. APN # LAND US PLICATION # STATE ZIP �— PHONE #2 EXT. ( ) BOS DISTRICT! w::=[ AT19P CODE qa I CONTRACTOR / SERVI;IQI +, QU STOR REQUESTOR COMMENTS: > D T c TO l%c-F-If 7N -C- THS W&:9'i L L( L 7-H 6 I ACCEPTED BY: • . CHECK If BILLING ADDRESS �� 0.h+` Date Service Completed (if al ady completed): BUSINESS NAME SERVICE CODE: t 1 PIE: Fee Amount: ° PHONE# J p EXT. Payment Date t WN Invoice # Check # k -Lw HOME or MAILING ADDRESS ' ? `'. FAX # CITY STATE ZIP �— BILLING ACKNOWLEDGEMENT: I, the upc( rki ned property or business owner, �erator or authorized agent of same, acknowledge that all site and/or project specificj�NVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. % APPLICANT'S SIGNATURE:�a k I �,- i�C f•( -e ^y-, DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT Is not the BILLING PARTY, proof of authorization to Sign Is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED: O V o COMMENTS: > D T c TO l%c-F-If 7N -C- THS W&:9'i L L( L 7-H 6 I ACCEPTED BY: EMPLOYEE M . ASSIGNED TO: EMPLOYEE M DATE: l Date Service Completed (if al ady completed): SERVICE CODE: t 1 PIE: Fee Amount: ° Amount Paid l 3 Payment Date t Payment Type Invoice # Check # k -Lw m @ Received By: f>� i VE EHD 48-02-025 tl01I 6) j 2017 SR FORM (Golden Rod) 07/17/08 SAN JOAQU!N COUNTY. ENVIRONMENTAL � NIEALTH DEPA1,7-MENrj ,Vkf