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IL SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTH Ok-ARTMENT SERVICE REQUEST Type of Business or Property tkm- RECEIVED FACILITY ID # ( SERVICE REQUEST # OWNER / OPERATOR BUSINESS NAME .(=�L CHECK If BILLING ADDRESS FACILITY NAME (� EXT. HOME or MAILING ADDRESS SITE ADDRESS -7 *7 7 --7 Street Number VAI Direction ySe , t �-� Street Name r�►�-r 7`�� f; cityZip / 533 7 Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number CITY /�a �Z G� Street Name CITY STATE ZIP PHONE #1 EXT. ( ) APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR RECEIVED BILLING ACCEPTED BY: CHECK If ADDRESS BUSINESS NAME .(=�L DATE: 7_ (M 7 PHONE # ?2S EXT. HOME or MAILING ADDRESS DATE: I FAX # 23vi �c �✓ " a i-r•�/G✓ PIE: �7 2 (7�s"') 2e3 —lGjc� CITY /�a �Z G� STATE..4 ZIP 9,5 7 C 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 appli and tha the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S laws. APPLICANT'S SIGNATURE: DATE:../ PROPERTY / BUSINESS OWNER PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 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 ISrovided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: UST uiluh t RECEIVED COMMENTS: rEti 0 6 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 0EPARTMENTj ACCEPTED BY: EMPLOYEE #: DATE: 7_ (M 7 ASSIGNED TO: EMPLOYEE M DATE: I Date Service Completed (if already Completed): SERVICE CODE: V PIE: �7 2 Fee Amount: 1 Amount Paid Imo! Payment Date Payment Type G L Invoice # Check # -' Received By: ss c_ EHD 48-02-025 SR FORM (Golden Rod) 07/17/08