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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property COMMENTS: (%L�! f=y 0 F At 411-4,-/0 —T?) —"7-t IE E )<-IS T/J c�Lr. 47 7 FACILITY ID # EMPLOYEE #: SERVICE REQUEST # ASSIGNED TO: S i Dt�Ot.«vS EMPLOYEE #: DATE: Z f lD Date Service Completed (if already completed): 777 n/ OWNER / OPERATOR__ Fee Amount: >< 3 p . C� Amount PaidcoU Payment Date Payment Type CHECK If BILLING ADDRESS FACILITY NAME Received By: SITE ADWI-0-7 O S f uln#w rf �u�y e -A �.3 Street Number Direction Street Name CI Zi Code Hai Or MAILING ADDRESS (If Different from Site Addre s) // /& / �d Street Number Street Name I STATE ZIP Y PHO C #1 L � /) EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATIONCODE CONTRACTOR / SERVICE 4UESTOR _ REQUESTOR yiy�+ i�` w c b — S CHECK if BILLING ADDRESS m 0 I 1R PHONE# EXT. BUSINESS NAME �� X��,, 1 ^i ,ter HOME or MAILING ADDRESSyr '1 ��(t i� FAX# CITY ` r . STATE ZIP 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 appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA and FEDERAL laws. J APPLICANT'S SIGNATURE: DATE: 2/77 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY. Proof of authorization to sign is required Title AUTHORIZA TION TO RELEASE INFORI'dIATION: 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: COMMENTS: (%L�! f=y 0 F At 411-4,-/0 —T?) —"7-t IE E )<-IS T/J c�Lr. 47 7 ACCEPTED BY: C i L)£ l EMPLOYEE #: r DATE: / f If ASSIGNED TO: S i Dt�Ot.«vS EMPLOYEE #: DATE: Z f lD Date Service Completed (if already completed): 777 SERVICE CODE: Lf i Pi W Fee Amount: >< 3 p . C� Amount PaidcoU Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 07/17/08 PAYMENT RECEIVED :r 042016 SAN JOAQUIN COUNTY ENVIROMENTAL MIFAITH DEPARTMENT SR FORM (Golden Rod)