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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business Or Property 5 FACILITY ID # SERVICE REQUEST # COMMENTS: ry s2 Z)6'7 33 OWNER / OPERATOR CHECK If BILLING ADDRESS❑ o // e, 7f FACILITY NAME doe_ HOME or MAILING ADDRESS O� dow✓ ICr •B.F'OL 1" Orr B �Cc� SiTEADDRES$ STATE ZIP ✓cam. fns"3.ZD Street Number 0 a s ACCEPTED BY: CI 7JD Code HOME or MAILING ADDRESS (If Different frarn Site Address) I DATE 1 O ASSIGNED TO: ` r Street Number sv..t Nam. CITY STATE ZIP PHONE#1 Fee Amount: APN # LAND USE APPLICATION # (Rd9) I Payment Date a;2-7-1sY-0/ PHONE#2 En. BOS DISTRICT LOCATION COOS (zd) 523— Y o0 0 1p CONTRACTOR I SERVICE REQUESTOR REQUESTOR 5 Pqy COMMENTS: CHECK If BILLING ADDRESS BUSINESS NAME / COrri J� PHONE# EZT. ,t.. c�/O J a/r 2d doe_ HOME or MAILING ADDRESS FAX# CITY STATE ZIP 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 JoAQUDa CODNTY Ordinance Codes, Standards, STATE and FE=DERAL laws. APPLICANT'S SIGNATURE: 404"' �� f DATE: 1O1 -12117 T PROPERTY / Busn'iEss OWNER[] OPERATOR /MANAGER ❑ OTHER AUCHORI'LF.D AGENT er If APPLICANT is not the B/LLINO 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 is provided to me or my representative. TYPE OF SERVICE REQUESTED: p 5 Pqy COMMENTS: rTtcETwo OCT 30 2017 H EN'l'/RDN A'c00 "I DEAEAs a s ACCEPTED BY: O�- EMPLOYEE M 14 SIB G) I DATE 1 O ASSIGNED TO: ` r EMPLOYEE #: " S 6 9 DATE: 10 Date Service Completed (if already completed): 1O—SC)— SERVICECODE:-.�5��_j 010 k I P/ E: Fee Amount: , SZ '7- Amount Paid \S2 I Payment Date \O — --a>0 Payment Type Invoice# Check# bS I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003