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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # A q SERVICE REQUEST # r-UU" . V,;Z35 OWNER/ OPERATOR 75y, e62 v` t CHECK If BILLING ADDRESS FACILITY NAME C G HOME or MAILING ADDRESS 20 Fee Amount: SITE ADDRESS4treet h umber i ec to ` �e rest m� CITY 1 � t Q Y1/T CL�C� itv / Cde HOME Or MAILING ADDRESS (if Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT' (101) 1.7 APN # b 1 LAND USE APPLICATION # ti PHONE#2 EXT. BIDS DISTRICT JLOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME t C0.rc-n I �' i T� PHONE# ExT' ,4 v` t PC' SERVICE CODE: 199P HOME or MAILING ADDRESS 20 Fee Amount: FAX # , Amount Paid �b �— Payment Date IO 4 CITY STATE 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 done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE nEDERAL laws. q -7 APPLICANT'S SIGNATURE: �'/r DATE: ``4?- /// PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTEY � h (/" T c 6L If APPLICANT is 1101 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. I]EAI.Tli DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. T TYPE OF SERVICE REQUESTED: COMMENTS: RECEIVED OCT 0 5 2017 >N JOAQUIN COUNTY ENVIRONMENTAL ""AI.TH DEPARTMENT ACCEPTED BY: Ll `l ( n n EMPLOYEE M t ! C"'(") DATE: ASSIGNED TO: - ` / 1, 11 ' EMPLOYEE #: )'Z- DATE: — Date Service Completed (If already completed): SERVICE CODE: 199P 1 E: �C Fee Amount: Amount Paid �b �— Payment Date IO 4 Payment TypeLlL Invoice # Check # G Received By: EHD 48-02-025 REVISED 11/17/2003 V SR FORM (Golden Rod)