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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UtPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR CHECK if f-_—%.\ (i&2. BILLING ADDRESS FACILITY NAME ejl-rei\Ly it----7-9---S. Li 0/0/4 a'.-74 I-CIL. SITE ADDRESS 1 ../..i I Street Number Sb Direction iligiC a S treet Name .5-rec_A-0-t-1. 9'571)C Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) ., 1xi...%t_550‘_ t.....-.'Y Street Number Street Name CITY STATE ZIP (---t5 .7 63 PHONE #1 EXT. (lift) 1-9, 7.2 G3 APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR AAA- (...-_, L CkAo \ Q 2. Alk_AIL CHECK if BILLING ADDRESS BUSINESS NAME PHONE # (20 ) 2 ,--p--/-2-2_SS' ExT () Pe, (c-eAnne. .i5owki'S < HOME MAILING ADDRESS lir or FAX # ( ) 3_12:3 i cines5c-A_ kkicil CITY Stuc_ .._..tue_.) STATE -. , ZIP Ci -.,.:),2_0 5 APPLICANT'S SIGNATURE: PROPERTY/BUSINESS OWNERA OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING 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: -74-rilkAfT kvec COMMENTS: EWE ^ L./ i\ ftw kiLe...V \i CtiLi FE8 n 0 v 4 2018 SAN jo4Qui H4N, ,VIRON4IcC,PUNTy 1-1 H DEp '-'vrAL AR-rwArr ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date / Payment Type Invoice # Check # Re eived By: d(() 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 Of activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applipation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA7E and EDUZAL laws. (4E7 OZ. DATE: ,,y2.1;zhs EHD 48-02-025 SR FORM (Golden Rod) 07/17/08