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SAN JOAQUIla'C;OUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property WM`t FACILITY ID # BUSINESS NAME SERVICE REQUEST # PHONE # EXT. J �. 'co ®� HOME or MAILING ADDRESS ` -� RECEIVED c CITY STATE ZIP , C�,P DEC 0 9 2014 OWN R / OPERATOR SAN JOAQUIN &OUNTI ENVIROMENTAL ACCEPTED BY: CHECK if BILLING ADDRESSC� FACILITY NAME r DATE: t �R ME I { 7 v Fn( SITE ADDRESS I 4 C� SERMCE CODE: PIE: Z30 - Fee Amount: �Zi Street Number Direction to ame Ci Invoice # Code HOME Or MAILING ADDRESS (If Different from Site Address) Check #366 Received By: Street Number Street Name CITY STATE zip PHONE #1 ExT• APN # LAND USE APPLICATION # PHONE R ExT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR WM`t CHECK if BILLING ADORES BUSINESS NAME y /— c' PHONE # EXT. P: 4 Jl39L—zAl HOME or MAILING ADDRESS ` -� RECEIVED FAX # 4-, CITY STATE ZIP , C�,P 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 JOAQUIN COUNTY Ordinance Codes, Standards, STATE a:!, FEDE L laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ h /, Cly r 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: Replace iirep4k ".- t t r COMMENTS:tc y /— c' � C RECEIVED DEC 0 9 2014 SAN JOAQUIN &OUNTI ENVIROMENTAL ACCEPTED BY: CX EMPLOYEE #: DATE: t �R ME ASSIGNED TO: { 7 v EMPLOYEE #: DATE: Date Service Completed` (if already completed): SERMCE CODE: PIE: Z30 - Fee Amount: 3 v Amount Pai 3 ��, D Payment Date 9 Payment Type Invoice # Check #366 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 N