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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# EL / /09i �P001(QIS( OWNER/OPERATOR DS *HtV CHECK If BILLING ADDRESS FACILITY NAME / 1 / r� SITE ADDRESS 39,00 W /0">O� ROA D r� 9,S�q Street Number Dlreclion Street Name CIG Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EZT. APN# LAND USE APPLICATION# vo ) 83s 4(, 7.,-- a f.Z—o4o -oa UP- ao PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( I CONTRACTOR/ SERVICE REQUESTOR REQUESTOR PO/VI C � CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. /VE 016151406 44-01? HOME Or MAILING ADDRESS FAX IV 2) ^:2"b CITY O( STATE n^ ZIP C3 / 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 application and Pt the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, PEE and FEE) laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT IS not the BILLING PARTY proof of aut onoation to sign is required Titte 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 t0 me Or my representative. / TYPE OF SERVICE REQUESTED: rgArcLOA P/ SOL rE W COMMENTS: � yr14 RECEIVED NOV 0.1 2016 SAN JOAOUI COUNTYPmvinOMENT ACCEPTED BY: kniva - EMPLOYEE#: ItMATEt IH11E (4Q'I-N ASSIGNED TO: -red (A O EMPLOYEE M DATE: It I Date Service Completed (if alrea y completed): SERVICE CODE: SC rJ�3 IP/E:,2�Q0 Fee Amount: Lp tY I S Amount Paid (/ 5- 1 Payment Date /I t t 6 Payment Type Invoice# Check# -3 C9 C_7 Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08