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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UCPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # U 0 L �. S�L� S � 0 C> (z c, -7s- -� L4 -*I c, CITY OWNER /OPERATOR AUG 2 7 2013 9n ( N /t � � -D r I �-! �' u I 0FWI V CHECK if BILLING ADDRESS FACILITY NAME Go ( K, _ "— S � SITE ADDRESSRo S 7 !�6 / l— l �J (Code1p Street Number Direction Street Name DATE: cit Zit) HOME or MAILING ADDRESS (If Different from Site Address) Street Number r Y4j Street Name CITY STATE zip PHONE #t ExT. APN # LAND USE APPLICATION # Rc )46z, �V7q 16':� -- I t� >— G G/ Amount Paid �� PHONE #2 ExT. BOS DISTRICT LOCATION CODE Invoice # Chec I Received By CONTRACTOR/ SERVICE REQUESTOR REQUESTOR �) llQU �i / 1 �( (�M. (c- CHECK if BILLING ADDRESS 13 �t J�-r�1�1- I�� BUSINESS NAME N / �) "�,,� PHONE# EXT. HOME or MAILING ADDRESS FAX CITY STATE (2fz�'- ZIP 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 do a� lInccordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. �(�(-�....L T; ?- 2 7- / 3 -109112 APP'LICANT'S SIGNATURE:T46� DATE: 'S— o"? 7 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER 6 OTHER AUTHORIZED AGENT 2r AGE* - If APPLICANT is not the BILLING PARTY proof of aut%rorizat/on 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:NT i , PAYM E "�,,� COMMENTS: AUG 2 7 2013 SAN OALNTY ENVIARCOMENTOUIN HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: - DATE: ASSIGNED TO: r Y4j EMPLOYEE #:f i / DATE: Date Service Completed '(ifalreadycompleted): SERVICE CODE: d-� �� PIE- Fee Amount: + �� `_� Amount Paid �� Payment Date ! Payment Type V1 Invoice # Chec I Received By EHD 48-02-025 07/17/08 lof�C1 ��.1'J $' SR FORM (Golden Rod)