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SAN JOAQUIN LOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> d"AO�ua�la�i �Oo�s�l� <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMP <br /> h �veYp/ <br /> SITE ADDRE S p/[� el /,Z,"P G h <br /> gy9C ee[iumbf DI...Non Ip Coda <br /> HOVE Or P LING A RES Of Different fr m Site Address) <br /> ✓'P Street Number Street Name <br /> C,l C'k 4in <br /> 4 STAT E/ zip <br /> P'IONE#1 ET' APN# LAND USE APPLICATION# �f G- <br /> ( l <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> l <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS PHO T <br /> HOME or MAILING ADD! s§ FAX if <br /> 7514c) 5, 4a e ✓c ( ) <br /> CITY STATE CA zip S <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application d th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and EDE la <br /> APPLICANT'S SIGNATURE: ©� DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of Whorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable: I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmentai/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a5 It IS available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: OU�' del rfq ED <br /> COMMENTS: <br /> AUG 26 2016 • <br /> SAN JOAQUIN COUNTY <br /> ENVIRO PppI'MENT <br /> HEATH D <br /> ACCEPTED BY: V40.4ed ra-Z/, EMPLOYEE#: DATE: <br /> ASSIGNED TO: G 2ahante <br /> U (/'/" I r-e L 7 EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: V?>/1/„/tZ <br /> Fee Amount: �-7 (� Amount Paid a 7 8 O Payment Date %1;;6 <br /> Payment Type C Invoice# Check# (0 ,0—T Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />