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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR I CHECK it BILLING ADDRESS 1—i FAGuTy NAME Li SITE ADDRESS L 11 Street Number Direction.� ky An Code Nam c HOME or MAILING ADDRESS (if Different from Site Address) Sireat Number Street Name E—Ty STATE zip PHONE#1 APN# LAND USE APPLICATION# PHONE#2 Exr. BOS DISTRICT —7FLCCATFON CODE CONTRACTOR i SERVICE REQUESTOR REQU=-STOR CHECK if BILLING ADDRESSLri BUSINESS NAME PHONE# EM HOME or MM_LING 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 ENviRo,4mEN'rAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to nic 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 JOAQUIN COUNTY 0mlinance Codes,&ondards,STATE and FEDERAL 1aw5. APPLICANT'S SIGNATURE: PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT ]f,4PxjcAArT is not the BILLING P.,11? proof oftiutliori.-ationtosign isrequired Title AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,tile 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 DVARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERvicE REQUESTED: COMMENTS: V [z U DEC 2 0 2017 ACCEPTED BY: EMPLOYEE AsSIGNED TO: EMPLOYEEiV: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Typ, Invoice# Check# Received B EHO 48-02-025 SR FORM(Gal,ocn Rod, REVISED 1111712003