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SAN JOAQM COUNTY ENVIRONMENTAL HEALTT 1, .eARTMENT SERVICE REQUEST Type of Business or Property 1=FACILI'TYC'r PHONE# EXi' HOME Or MAILING ADDRESS ERVICE REQUEST d A IeV (419 P7100 0 RECEIVED CJI-OAAr .5"e � - OWNER/OPERATOR CHECK If BILLINGADORESS❑ Gum ee T i l to FACILITY NAME ENVIROMENTAL ACCEPTED BY: 00 , SITE ADDRESSr " We �.L�QT10 �i"1� ASSIGNED TO: crl_�v EMPLOYEE #: V Street Number Di r.t Str me City Zi Cotle HOME of MAILING ADDRESS (If Different from Site Address)CANNA Fee Amount: �1ZS C MCI, Street Number Payment Date Street Name CITY ( ` ••ty N STATE ZIP ��r� Check # 31 s E APN# PHONE yQ] (`J� LAND USE APPLICATION# PHONE#2 EXT. - BOS DISTRICT LOCATION CODE V CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXi' HOME Or MAILING ADDRESS FAx# 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 ENVIIdONNfENTAL 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: ? DATE: 6 PROPERTY/BUSNESS OWNERZr OPERATOR/NIANAGER ❑ O—Ta,, AUTHORIZED AGENT❑ 1f APPLICANT is not the BiLLINGPAR7Y 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: UST L -8Y Is- L& -/4)Y 1 PAYMENT COMMENTS: RECEIVED CJI-OAAr JUN 0 9 2014 SAN JOAQUIN COUNTY ENVIROMENTAL ACCEPTED BY: 00 , Aj+-t 12- LI EMPLOYEE #: DATE: ASSIGNED TO: �-� EMPLOYEE #: V DATE: Date Service Complete (if already Com ed): $ERVICECODE: 0� f PIE: 2 / Fee Amount: �1ZS Amount Paid Payment Date Payment Type_ Invoice # Check # 31 s Received By: EHD 48-02-025(1 �, cG \n _` �7 I SP—bO( 9 $O Z SR FORM (Golden Rod) REVISED 11/17/2003 1 `�' T L ��- S Ste. oo(.9 $C)'