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SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # 467—AG Al 7n ,y 0 0 SERVICE REQUEST # /1 EXT. ( Z- S HOME OT MAILING ADORES$ /-, EMPLOYEE #: DATL: (AX # ) EMPLOYEE #: DATE: OWNER / OPERATOR I S 4 / STATE kdf CHECK If BILLING ADDRESS FACILITY NAME 10 �. -CCC" Check # ( (Z - �Cvvtc�Alock1t;- t SITE ADDRESS �33 V. r Avg oc�� . �ZpCd treet Number rection GUp ULStreet Name Ctt Zi Code HOME Or MAILING ADDRESS (If Different from Site Address)J%iC /7 % G'1 Z ` (� ° X l [Street Street Number Name tt CITY ) V�[j STATE C4 ZIP^, 77 PHHOyNE #1 �( EXT. (Coy() (31 lUct'd APN # IW3�5�� LANJD-W3 APPLICATION # .`, PHONE #2 EXT. 1�003 DISTRICT LOCATION CODE CONT.F F C,,V 0*012 REQUESTOR4• 'v '��' J 4'\i,� ,�}�S .,• ,a,,,•`'`Ca`C• CHECK If BILLING ADDRESS BUSINESS NAME / ( f`C�C� tr,i. '� �f 4 s r� 'F✓ t 467—AG Al 7n ,y 0 0 PHONE /1 EXT. ( Z- S HOME OT MAILING ADORES$ /-, EMPLOYEE #: DATL: (AX # ) EMPLOYEE #: DATE: CITY (It6 I S 4 / 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. also certify that I have prepared this appl'Cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST and FE RAL laws. / L / APPLICANT'S SIGNATURE:4� DATE: �( PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT q [h4 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 to the JAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the -ame time it IS p;ovideri t rrs or mN representative. TYPE OF SERVICE REQUESTED: `e� COMMENTS. -r0 /Cw -�rr w v�yeK .34-/ F rGl� 7 467—AG Al 7n ,y 0 0 ACCEPTED BY: EMPLOYEE #: DATL: ASSIGNED TO: Date EMPLOYEE #: DATE: Sar vita "bassi iletad (if already completed): SERVICE CODE: P i "�O-7 _ f� Fee Amount: 2* o. I b Amount Paid cZ (� d 0 Payment Gate ; / a U Payment Type GCL Invoice # Check # ( (Z Received By: EHD 48-02-025 07/17/08 PAYMENT' v REGE,§141-IRM (Golden Rad) APR°2 0 2016 SAN JOAQUIN COUNTY EN'JIROMENTAL