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Belshire Environment Fax: (949) 460-5210 �To: 12094640138@rcfax.cc Fax: +12094640138 Page 1 of 1 11/26/2014 10:19 SAN JOAQUIN C614TY ENVIRONMENTAL HEALTH DEPAOMENT SERVICE REQUEST Type of Busingss or Property r ' /� FACILITY ID # SERVICE REQUEST # �- � C AD 6 ?U P # ExT. HOME or MAILING ADD SS OWNER %PERA OR CHECK If BILLINGADDRESSE] C,C C STATE ZIP r , FACILITY NAM � , �1 • � ' ;SITE ADDRES ( �� J�SCreEtber /% J�% EMPLOYEE M DATE: ASSIGNED TO: _ Direction CS e tTMm DATE: HOME or MAILING ADDRESS, (If Different f Site Address) P I E: Fee Amount: <ff— 10 < ' Street Number Payment Date Street Name CITY - �' STATEq.—Z.7 1P PHONE 91 EXT. Received By: APN # LAND USE APPLICATION # PHONE #2 Exr. ( 1 BOS DISTRICT oo'l LOCATION CODE 1 v1 CONTRACTOR / SERVICE REQUESTOR , REQUEST OR�— /J ' /� CHECK If BI LING ADDRESS BUSINESS NAME AD 6 ?U P # ExT. HOME or MAILING ADD SS AX# CITY j STATE ZIP r , 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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and E APPLICANT'S SIGNATURE: DATE: �l J PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILL/NGPARTY, 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. w_AYAN A,,. TYPE OF SERVICE REQUESTED: (,i S l I Zf-,fa, t ?VrcENE COMMENTS: AD 6 ?U Th ACCEPTED BY: � �� '� EMPLOYEE M DATE: ASSIGNED TO: _ EMPLOYEE M DATE: Date Service Completed (If already co leted): SERVICE CODE: P I E: Fee Amount: <ff— 10 Amount Pa' 3'7d DD Payment Date Payment Type Invoice # Check # 62-750 Received By: EHD 48-02-025 REVISED 11/17/2003 Received Time Nov.26, 2014 10:14AM No,7614 SR FORM (Golden Rod)