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SAN JOA ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Proper;: FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS W L L-G—offZOc— <br /> (—P-7 F5 Stmt hhnnOr r D!r-rr Leet Name city Zip Code J <br /> HOME or MAILING ADDRESS (if Different from Site Address`)) <br /> lJ� Cp ✓ vO Street Number Street Name <br /> CITY STATE ZIP <br /> c7N �Al2 f, , 7 4�'�� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 59 i -3 <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME t �S/r , P('-y- 1 �-, G` - E�'•� <br /> 1 v / lTly L3 ILS-r l`` '.� <br /> HOME or MAILING ADDRESS 03-707 FAX# <br /> CITY Q+ STATE ZIP C <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized T <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated witD <br /> or activity will be billed to me or my business as identified on this form. MAY 2Q �p <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance v iOSAN 7c'SA418 <br /> COuN'I1'Ordinance Codes,Standards,STATE and FEDERAL,laws. �j�RQU/N CDUNTM <br /> NTiq� <br /> APPLICANT'S SIGNATURE: DATE: [ €p T <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER EJ OTHER AUTHORIZED AGENT <br /> IfAPPLICAN'I'is nol the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to tfie SAN 3oAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andl5iir.1� nine- ll ii_ <br /> provided to me or my representative. w �� �/E D <br /> TYPE OF SERVICE REQUESTED: � 2 �( t v , p� r L. J1 <br /> COMMENTS: l-J-roti (2�S ��Z. L.L�/ p��V e �V MAY 2 9 2018 <br /> ENVIRONMENTAL IILAU1 11 <br /> an OgQa- DE13ARTNIENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> gcgl�N�ED TO: L 1cL, EMPLOYEE#' nATE: ZC7 I vGJ <br /> Date Service Completed (if already completed): SERVICE CODE: Gam-23 PIE: I <br /> Fee Amount: $ L-IS( Amount Pai .OD Payment Date S'Zl 1F <br /> Payment Type 1K Invoice# Check# �.jGS Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 94�q'�-7 --7 � <br />