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Title SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH JEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 5A007WO17 OWNER /OPERATOR 4-1-1,_ 2...4..„,, L 7-4't-/72 7:,-e?' ,,-?._--fe -- i'd3-)1,,f_ CHECK if BILLING ADDRESS FACILITY NAME 1 ' 1 / : ... ',.- (I SITE ADDRESS Street Number Direction , I Street Name City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. ( ) APN # I LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT II LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR <--"" . CHECK if BILLING ADDRESS BUSINESS NAM //..e--e-<:--_---- ,.. .::::-.,-;-1.....,:d- PHODIOL— .„. '7 - ' „ EXT . -- HOME or MAiLoG7A,7ESS . CA..) • 1,1.6" ---k- ir---/4.',/ /9-e - FAX # -----.---r ( ) CITY " STATE 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 applicati nd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S-rA APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT44--- DERAL laws. DATE: If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION 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: -7/ a ( ' ',—).`_-_:,i k I (.." . I (j ' 'AYMENT COMMENTS: RECtIvED AUG 1 1 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: ... cf, 1, i EMPLOYEE #: DATE: 51. zi_ I-) ASSIGNED TO: ('jr rAA.eSc ra EMPLOYEE #: DATE: 48k .2. I .- 17 Date Service Completed (if already completed): SERVICE CODE: 0 k, ( P/E: ned 2 Fee Amount: IS 2.106 Amount Paid Payment Date 4 1 - i Payment Type Ct../ 1 Invoice # Check # Received By: -_-----/- EHD 48-02-025 SR FORM (Golden Rod) 07/17/08