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SAN JOAQUI&OUNTY ENVIRONMENTAL HEALTIREPARTMENT SERVICE REQUEST Type of Business or Property pew FACILITY ID # SERVICE REQUEST # � - PHONE# 1/6 EXT' 57 HOME or MAILIN ADDRE HOME a�j ENVIRONMENTAL FAX# ©C� X OWNER / OPERATOR ( 1 CITY L Sys CHECK If BILLING ADDRESS FACILITY NAME DATE: 4- -,)—Ci _ /] ASSIGNED TO: `Z_f t SITE ADDRESS EMPLOYEE #: DATE: .4 ;?-Cl . / Date Service Completed If already completed): SERVICE CODE: 19? 6R 57 75— Street Number Direction Street Name Amount Paid city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Type Invoice # Street Number Receiv d By: Stm-st Name CITY STATE ZIP PHONE #1 ( 1 Err. APN # �2-t)b _)61a LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE ( ) c" t '� CONTRACTOR / SERVICE REQUESTOR REQUESTOR / ,V pew CHECK if BILLING ADDRESS 10 BUSINESS NAME -L 'I G/iU�../ � - PHONE# 1/6 EXT' 57 HOME or MAILIN ADDRE HOME a�j ENVIRONMENTAL FAX# ©C� X N ( 1 CITY L Sys STATE e n ZIP 05-76., 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 JoAQutN COUNTY Ordinance Codes, Standa!a� ATE and FEDERAL laws. APPLICANT'S SIGNATURE: ( _ DATE: 4 " CQ /"/5_ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT KI 1 O 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 tl F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availableari the same time it is provided t i� m representative.No'w TY U TED: Q P_ 0),4-,-,o U pew COM�o� oJ�t APR 2 4 2015 PQ ENVIRONMENTAL pAcp&�►�'-o SPN�N�NO�e HEA ERMIT/SERvIres N ACCEPTED BY: 1 ry C EMPLOYEE #: DATE: 4- -,)—Ci _ /] ASSIGNED TO: `Z_f t EMPLOYEE #: DATE: .4 ;?-Cl . / Date Service Completed If already completed): SERVICE CODE: 19? P 1 E: Fee Amount: Amount Paid l'd. � Payment Date a �" Payment Type Invoice # Check # /jQ �—/ 5-070 Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 TH