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y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# g(L 067 5q�,l OWNER/OPERATOR 0. CHECK If BILLING ADDRESS FACILITY NAME i O '^ SITE ADDRESS 5 l/.•('I�jt no SITE l 7 Street Number Direction t/ '• �Stroot amo? !/ �v �✓ ` ��O� Ci,• _.c Cotic HME Or MAILING ADDRESS (If Different from Site Addr ss N ) Street Number CITY STAT ZIP 1 ' I C � � G [-r � J PHONE#1 ExT. APN# LAND USE APPLICATION# (zoy) 2 0/Z�7 7 PHONE#2 Err. BCS DISTRICT LOCATION CODE ( I CONTRACTOR SERWCE REQUESTQR REQUESTOR CHECK If BILLING ADDRESS I_E o e>`1r [ti BUSINESS NAME PHONE# ExT. 2, q 7 HOME or 1 MAILING ADD ESS FA%#Z CITY .F—O / I ,J— STATE !' 2ZIP O� 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 and FEDERAL laws. APPLICANT'S SIGNATURE: d- rL � DATE: /r / 2-4:y r1 �4/� PROPERTY/BUSINESS OWNER f OPERATOR//MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it is provided t0 me Or my representative. all MENT TYPE OF SERVICE REQUESTED: ` ( P.i S Gf'fa/I COMMENTS: AUG 15 2016 SAN JOAQUIN COUNTY ENVIROMENTAL FIEALTR DEPARTMENT ACCEPTED BY: EMPLOYEE#: DATE: Cr_ ASSIGNED TO: 5 '� EMPLOYEE#: DATE: CCQ/r/ Date Service Completed (if alreadycompleted): SERVICE CODE: Olt P/E: J Fee Amount: Amount Paid I3 . cP0 Payment Date g.. t S - J Payment Type C Invoice# Check# Received By: ;7 1 EHD 48-02-025 07/17/08 SR FORM(Golden Rod)