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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR CHECK if BILLING ADDRESS❑ Sok xe�( Car v t I I FACILITY NAM[—�— + . .SITE ADDRESS L W Str¢el Number r LI u U CI Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) r/' 1-1OdSO4 1-1SSf, Street Number Street Name CITY C-�G c v—+O'r\ STATE n yl _ ZIP q 5'Z a C PHONE#1 �' APN# LAND USE APPLICATION PPLICATION# ( J -J (2M) aLly-+ PHONE#2 EXT. BOS DISTRICT LOCATION CODE 120 9) stbS 9 !(9 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR/ `/ Ov %Ik- t/1IIa1tvedr^ CHECK If BILLING A0DRE5S BUSINESS NAME !� r PHONE# ExT. �O-rrI, O to04S 2Q4t 5Ss 97(65 2a`i96s 4y� HOME or MAILING ADDRESS FAX# )L(Ldta E- Ltnc( Sa 4� I ) CITY SkO C'LAvV\ STATE Cpt ZIP CISZ65 BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. l / APPLICANT'S SIGNATURE: r0� DATE: PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHDRRED AGENT ❑ 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it is available and at the Same time It IS provided t0 me or my representative. �{'� yPOMMENT TYPE OF SERVICE REQUESTED: rood °`/e I 1 L U. MU E-TVED COMMENTS: NOV 3 0 2016 SAN JOAQUIN COUNT ENVIROMENTAL q r HEALTH DEPARTME ACCEPTED BY: W Qi '(.I n,j/h EMPLOYEE M DATE: ASSIGNED TO: L, I1GLUt1 h N EMPLOYEE DATE: Date Service Completed (if already crompleted): SERVICE CODE: SL V U I PIE: L -77 Fee Amount: I-j q Amount Paid 13 C' , SIJ CC Payment Date ll 3 C9 Payment Type Cct Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08