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W W SAN JOAQ N COUNTY ENVIRONMENTAL HEALTH QEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # FA boo t; f BUSINESS NR NE r� /� 1 /-C �I SERVICE REQUEST # 60-7 OWNER /OPERATOR ///jjj �� ^ (1 G / I V Y, Ie,1 , � � � 1 V CHECK If BILLING ADDRESS -- � FACILITY NAME / I S e ry J F%—TE7S FAX# SITE ADDRESS Street Number Direction ` ` aft re, tName DATE: f012-elf7 rvN Ci S3 Z () Zi Code HOME Or MAILING ADDRESS (If Different from Site Addre�;s) 0/ 1 Street Number Fee Amount: A'73tj •-L� Street Name CITY STATE ZIP m dou-h PHONE #� Ext. cop) �� - 660 APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT 1 71 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR W rt i1 VVIJ g� r j� r J CHECK If BILLING ADDRESS f BUSINESS NR NE r� /� 1 /-C �I OCT`2 8 2015 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT PHONE # U EXT r HOME Or MAILING A M A/ FAX# C!TY+ f c-7' 0 STATE Cis ZIP 17SL) 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. also certify that I have prepared this application and that the w t0 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA E and FEDERAL I ws APPLICANT'S SIGNATURE: DATE: j ()AS ;7U/S PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT /o Z- a" If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION_ TO RELEASE INFORMATION: When applicable, I, the owner of 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 t0 the or my representative. PAVMPNT TYPE OF SERVICE REQUESTED: t,IST Fl–e'4 •%� ^� RECEIVED rOMMEN7.' : 7h—lr k IJAo l OCT`2 8 2015 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT v_ ACCEPTED BY: EMPLOYEE #: DATE: �� /S ^ ASSIGNED TO: J //�/� n' j� /►�� "' — EMPLOYEE #: DATE: f012-elf7 Date Service Completed (if already completed): SERVICE CODE: Gam; � G� � P PIE �r Fee Amount: A'73tj •-L� Amount Paid Payment Date — Payment Type Invoice # _ Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08