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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REOUEST Type of Business or Property Ar&nAS CHECK N&LLNGADDRESS❑ 6Ze.y(" FACILRY ID # — Foci FSERVICE REQUEST # 6-71 c)-0 OWNER /OPERATORI NAOC �o5�'0mt �� CHECK H BILLING ADDRESS❑ FAaLnvNAME Lod; Up,-, Pi SCLOO� L 211 SITE ADDRESS ,,05 v,•ME s+Q STATE C A 75P g 1-73? EMPLOYEE #: g524a Sveet Number Direction DATE:2 Street Name C ZI e HOME or MAIUNG ADDRESS (If Different from Site Address) Amount Paid � 417 ,- Payment Date I Payment Type j S� Invoice # Stmt Number Received By. St,eet CITY STATE ZIP PHONE#1 �' APN # LAND USE APPLICATION # (7,09) 531- -4155 PHONE#2 P"r BOS DISTRICT LOCATION CODE CnNTRACTnR /SERVICE REOUESTOR REQUESTOR - J -a b a izto Ar&nAS CHECK N&LLNGADDRESS❑ 6Ze.y(" BUSINESS DAMEPHONE# La;-.) Foci EXT. (la to 44-OZ-C'a HOME or MAILING ADDRESS/A, I AamT� FAX 211 CITY S �/ JZ/ctin rL STATE C A 75P g 1-73? BILLING ACKNOWLEDGEMENT: I, d acknowledge that all site and/or projecTThidaFE) v or activity will be billed to me or my bden I also certify that I have prepared this and COUNTY ordinance Codes, Standa—rds, A property or business owner, operator or authorized agent of same, MENTAL HEALTH DEPARTMENT hourly charges associated with this project i on this form. the work to be performed will be done in accordance with all SAN JOAQUIN laws. APPLICANT'S SIGNATURE DATE: / PROPERTY/ BUSINESS OWNER❑ OP TOR/MANAGER❑ OTHER AUTHORIZED AGENT IJ 1140tm If APPL/CANT is not B/ LIN PARTY proof of authorizadon to sign is required Till e AUTHORIZATION TO REL E 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 is provided to me or my reoresentative. TYPE OF SERVICE REQUESTED: ew '�(� PpYwc:: kr- COMMERrs: E _, FEB 2 12017 SANJOAQ,q H L'h 0Ea�^MF�. , ACCEPTED BY: 61—V_t' (iS "V EMPLOYEE #: DATE: ASSIGNED TO: zb L EMPLOYEE III: DATE:2 Data Service Completed (if already completed): SERNCE CODE:5 Z 3 PIE Fee Amount 1'� Amount Paid � 417 ,- Payment Date I Payment Type j S� Invoice # Check# *- 152 3 0 Received By. REHD 48-02-025 EVISED 11117/2D03 �� rN ` �" V" 2-/9/17 ,,� �C7 C ✓edf ( SR FORM (Golden Rod)