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SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S -��-7Y91 OWNER/OPERATOR � CHECK If BILLING ADDRESS El n'l o✓t, (,(a✓�S rnct FACILITY NAME al � Q SvL Kart smv� �}✓ SITE ADDRESS Su>o 3 Street Number I DIree n Pe Yl"� Street Name " CI �Zip Code HOME Or MAILING ADDRES (If Different from Site Address) 2-6-ZqU Qdurro S q d Yc5nla. D6,r Street Number r) CI � STATE ZIP � n7z'acc%, (� 64 15337 PHONE#113 r)/3G EXT. APN# LAND USE APPLICATION# ( �) 6 7y PHONE#2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR � CHECK If BILLING ADDRESS BUSINESS NAME I I PHONE# EXT. HOME or MAILING ADDRESS /lS r FAX# v yq CITY �I STATE ZIP q/,S 3-2.0 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. also certify that I have prepared this*�F at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, L laws. APPLICANT'S SIGNATURE: DATE: 7-S - ZOi 7 PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® pl rcc' � Ei• 9" ✓mfr�O�s If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title T 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 t0 me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: Q art RECEIVED ED COMMENTS: JUL 05 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: G[; 1` EMPLOYEE#: �C�� DATE: -7 ASSIGNED TO: "�1V EMPLOYEE#: t�L�yw DATE: l Date Service Completed (if already Completed): SERVICE CODE: �--) � P I E: a Fee Amount: Amount Paid ' O v Payment Date ? S 7 Payment Type GLC Invoice# Check# Received By: p ZZ- 1 �2 EHD 48-02-025 -?12, 07/17/0/08 SR FORM(Golden Rod)