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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #U00 01 ERVICE REQUEST # / hl �C. %f J BUSINESS NAME t{ `,�" 7658q OWN /OPERATOR HOME or MAILING ADDRESS CHECK If BILLING ADDRESS FAX # I ` /C ASSIGNED TO: l ( ) FACIuTY NAME Date Service Completed (if already completed): STATE q57-77'V SERVICE CODE: i / - T / ZZ14-- Fee Amount: 1 -7 Amount Paid• SITEADDRESS Payment Date � Oi / Payment Type Invoice # Check # i2 Received By: LStreet Number Direction Street Nam Zf COCA HOME Or MAILING ADDRESS (If Different from Site Address) O L. G • L� Street Number Street Na" CITY STATE �, )ZIP , 6215"1. PHONE #t APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUEST? �� iV �,/��.//( CHECK if BILLING ADDRESS 01 / hl �C. %f J BUSINESS NAME t{ `,�" 44l. C PHONE# En' <�T '1 HOME or MAILING ADDRESS FAX # I c�.wo DATE: 1-7_ ASSIGNED TO: l ( ) CITY .�R ^ C , Date Service Completed (if already completed): STATE q57-77'V BILLING AC NOWLEDGEMENT: 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 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: e �1 9 C'�// DATE: /A- 7 PROPERTYI BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time it i! jp ,ded to me Or my representative. w kkjuN TYPE OF SERVICE REQUESTED: ` �CCe 'elloll;, COMMENTS: JAN 10 414 2017 EPF ACCEPTED BY: EMPLOYEE M DATE: 1-7_ ASSIGNED TO: l EMPLOYEE M DATE: / — /b - / Date Service Completed (if already completed): SERVICE CODE: PIE: J&,0 Fee Amount: 1 -7 Amount Paid• , v L) Payment Date � Oi / Payment Type Invoice # Check # i2 Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08