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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Res/omaA4- OWNER/OPERATOR OWNER/OPERATOR SHELGE /4LI M CHECK It BILLING ADDRESS Er ,* AI` Er FACILITY NAME SREADDRESS^7 E EAs�RArHEfyHT-s ,¢vAD I-11VDEW 95a3� a 14 4 Street Number OIrection Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) ,71 b*-7 h`E/yr(TS ,EGAD Street Number Street Name CITY STATE ZIP L/N EN CA �=23G PHONE#1 E%T. APN# LAND USE APPLICATION# 110 ) _ a a- a CC?IbZ PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) ZZ-A i (Al CONTRACTOR/ SERVICE REQUESTOR REQUESTOR 17 G' oA/ 4#e ;z/ PE CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. .5lVE CD s Lr d '491-1 J` HOME or MAILING ADDRESS FAX# CITY u STATE CA ZIP / BILLING ACKNOWLEDGEMENT: 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 a ��lication and hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ATE and FE laws. APPLICANT'S SIGNATURE: DATE:: oz PROPERTY/BUSINESS OWNER El OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT E 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. PAYMENT TYPE OF SERVICE REQUESTED: N/T rru'o COMMENTS: t5isrc 'Y I• l/UT �,_ a ' / y/G/�1_ v -( /v(2t�1 /lEtJTl�r� I'tB 0 2 2017 w/m Rb U /. E rcc` SAN JOAQUIN COUNTY Ajtbf�t �OR � � Z141'7 ® Cjcvsl.✓) ENVIRONMENTAL r- HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE:sv PIE: Fee Amount: G1 Amount Paid C� Payment Date f.2 Payment Type/ Invoice# Check#- LA ` Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08