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SAN JOAQ COUNTY ENVIRONMENTAL HEALTH _ .r'ARTMENT SERVICE REQUEST ype of Business or Property FACILITY ID# SERVICE REQUEST It Not o0 5 T/,Z-w 00-�?lie"9J/ 526�� 143� OWNER/OPERATOR CHECK((BILLING ADDRESS G7 LO " Z C• FACILITY NAME 6l . 7, D s . SITE ADDRESS ��t�$'- //ifr C7'f�4!/[ 4v (e ,5�-OC la lf. 'fit QS ZO Street Number-F Direction Street Name city Zio Code HOME Or MAILING ADDRESS (If Different from Site Address) 1 11 / e Street Number Street Name CITY ( STATE r ZIP r f � PHONE#1 EXT. APN# LAND USE APPLICATION# PHONE#2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. EL RF— 20 &/7 3f 7 HOME or MAILING ADDRESS FAX# Zi9s /Yiickf � Ave C c ) CITY - ?ZI /`to yr � STATE zip GS D BILLING A�'CuuKNO`WLEDGEMENT. 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 and FEDERAL laws. APPLICANT'S SIGNATURE: 0�, t�sr� DATE: 47 e" �) PROPERTY!BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THERU AUTHORIZED AGENT ❑ IfAPPLICANTiS 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 prO�q.�f(j me Or my representative. TYPE OF SERVICE REQUESTED: tile, COMMENTS: 194AII,10 0 2015 y�C Dt AR 744 MB in ACCEPTE BY: hn�� EMPLOYEE#: / DATE: ASSIGNED T0: z 1 EMPLOYEE#: DATE: Date Service Completed (If already completed): SERVICE CODE: Ob�/ PIE: O O 0( Fee Amount: / Amount Paid 13o.oa Payment Date Payment Type �� Invoice# Check# Received By: EHD 48-02-025 07/17/08 SR FORM(Golden Rod)