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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �►xr yr alp FACILITY ID # BUSINESS NAME jr--744 �"Nl✓Esi MATS /�G SERVICE REQUEST # toy (n3 C. x�e�t 6;�� x)/10 CITYk/f ✓/�i STATE G'� ZIP B J�/8 c�� OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ FACILITY NAME ENVIROMENTAL SITE ADDRESS tit T r ACCEPTED BY: EMPLOYEE #: 2-152, Street Number NOW. NOW. F heel N me DATE: C Zip C e }jOAle Or MAILINGID/DRESS (If Different from Site Address) Fee Amount: �-I'1 Amount PZ125T O(�{�j Street Number Payment Date Street Name CITY VA V %S /'� STATE ZIP 015618 Ezr' PHONE#1 API # LAND USE APPLICATION # 0159) -?E;i3 '71Z1 PHONE #2 EM. f ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR 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 in business as identified on this form. I also certify that I have prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards; ATE_ and FED RAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. PAYMENT TYPE OF SERVICE REQUESTED: -pSQ 1 REQUESTOR r,7,4je< - 1 .n, 1� CHECK If BILLING ADDRESS �rKF+ �I/IJ BUSINESS NAME jr--744 �"Nl✓Esi MATS /�G PN E# E� -7 7-M60 HOME Or MAILING ADDRESS GNIG FAX# ( ) x)/10 CITYk/f ✓/�i STATE G'� ZIP B J�/8 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 in business as identified on this form. I also certify that I have prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards; ATE_ and FED RAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. PAYMENT TYPE OF SERVICE REQUESTED: -pSQ 1 RECEIVE© COMMENTS: NOV 17 2016 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: RL�W11 !t 2 EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: SC Sa S P / E: b O Fee Amount: �-I'1 Amount PZ125T 7 b Payment Date -7 Payment Type C,{Ve6,k Invoice # Check # Recei d By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) C