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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER OPERATOR n v �i ❑ CHECK If BILLING ADDRESS FACILITY NAME SITE/ADDRESS /�lr�/ (�,•(T�/� n G MStreel Number I Direction HOME Or MAILING ADDRESS (If Different from Site Addres ) b Sheet Number Street Name CITYe�A— ZIIQ-4- z �p PHONE RI �� n— / ^ � T APN;0��/, /D� LAND USE APPLICATION# PHONE##�'2 �/ �( Far. `� BOS DISTRICT LOCATION CODE ( 1 004 11 9' CONTRACTOR/ SERVICE REQUESTOR REQUESTOR� CHECK if BILLING ADDRESS BUSINESS NAME N PHON EM' HOME or MAILING ADDRESS FAX# ( ) CITY P .w STATE ZIP BILLING ACKNQ LEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards,2JTE and F ERAL laws. Q APPLICANT'S SIGNATURE: DATE: V PROPERTY/BUSINESS OWNER EI 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 t0 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. " pWMENT TYPE OF SERVICE REQUESTED: NJI�rj'AQ. �t '= Qev Le vv NED COMMENTS: o //O�Md JAN 16 2018 AA!I& SAN JOAQUIN COUNTY, Ya lENVIRONMENTAL ` 11 G 3 �3 �'��lll p l HEALTH DEPARTMENT] ACCEPTED BY: IJII. 10'1 EMPLOYEE#: DATE: ASSIGNED TO: " JiC4EMPLOYEE#: DATE: Date Service Comp"d (if already completed): SERVICECODE: 157.2 PIE: •zGOH Fee Amount: C3014. Amount Paid 3 C Payment Date 6 1 ,K 1 Payment Type C L Invoice# Check# (� S Received By: EHD 48.02-025 /'/J! I SR FORM(Golden Rod) 07/17/08 �/ (/ I�u D7;