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SAN JOAQUNv COUNTY ENVIRONMENTAL HEALTH L_.1ARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING - DP.ES FACILITY ID # SERVICE REQUEST # COMMENTS: BUSINESS NAM I- m A 0OU 1- 14-1111 0&Lk;A) RECEIVED FEB 122016 SAN JOAQUIN COUN LNVIgCSMENTAL LIP.Ciii-ini-PARTMEN PHONE #T S3 7- &500 HOME or MAILING ADDRESS EMPLOYEE .Y: OWNER If OPERATOR lr�1 /' . l� CHECK If BILLING ADDRESS FACILITY NAME [ uA POt Nc o'4� J (M) 537 - (0549 SITE ADDRESS 3s�f SznT zip PS3o7 Pt�,'r lam Ole stook Street Number Dtre _, Slreet Amount Paid a C C-1Payment IN nn DntlP How.- or MAILING ADDRESS (If Different from Site Mdress) Invoice # - Check # III g StreetNumber Name CITY ____ __Street STATE zip PHONE #1 EaT ( _7Y APN # LAND. LAND USE -q� PHONE #2 --_ _ ErT DISTRICT LE LOCAT'ON CODE CONTRACTOR / SERVICE REQUESTOR REQU7.STOR / t(�b4xasb CHECK if BILLING - DP.ES `�I ~� ((WYY COMMENTS: BUSINESS NAM I- m A 0OU 1- 14-1111 0&Lk;A) RECEIVED FEB 122016 SAN JOAQUIN COUN LNVIgCSMENTAL LIP.Ciii-ini-PARTMEN PHONE #T S3 7- &500 HOME or MAILING ADDRESS EMPLOYEE .Y: FAX# .5200 Mo{51NacIr ASSIGNED TO: (M) 537 - (0549 CITY eyxt SznT zip PS3o7 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 FEDERAL laws. APPLICANT'S SIGNATURE: i /✓t.y�L"C�t/ DATE: a Ili I/G PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT/' WW6�asD If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required rlr7e 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 as it is available and at the Same time It i5 provided t0 me Or my representative. -^ TYPE OF SERVICE REQUESTED: I Q,��ck PAYMENT COMMENTS: RECEIVED FEB 122016 SAN JOAQUIN COUN LNVIgCSMENTAL LIP.Ciii-ini-PARTMEN ACCEPTED BY: EMPLOYEE .Y: DATE: '�? , 1 ASSIGNED TO: EMPLOYEE #: DATE: - Date Service Completed (If already completed): SERVICE CODE: Fee Amount: — Amount Paid a C C-1Payment Date U :;L Payment Type �� Invoice # - Check # III g Received By: M EHD 48-02-025 SR FORM (Golden Rod) 07/17/08