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Sep 05 18 04:27p JP n^troleum Service 91637 AR73 p.2 SAN JOA*NCOUNTY ENVIRONMENTALHEAL1IRLPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY 10 # SERVICE REQUEST # BUSINESS NAME r - �' - l { ) � X52 U�!L �j� 1/ I �C.r P N # E'rr' / c 37 v HOME or MAILING ADDRESS 7v OWNER / OPERATOR CITY /_ , , STATE CA ZIP 14c-6 rt / // ACCEPTED BY: CHECK if BILLING ADDRESS FACILITY NAME ASSIGNED TO: / EMPLOYEE #: ?j DATE: 71 Date Service Completed (if already completed): SERVICE CODE: SITE ADDRESS Fee Amount: ' Amount Paid �3t S Street Number Direction Street N City21 Coda HOME or MAILING ADDRESS (If Different from Site Address) Received By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # () 26 9� ys_ I-`E os 3 2 PNONE#2 EXT. l ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR T CHECK if BILLING ADDRESS V v"' BUSINESS NAME r - �' - l { ) � X52 U�!L �j� 1/ I �C.r P N # E'rr' / c 37 v HOME or MAILING ADDRESS 7v FAx#r2E I IG (o) <3-1a - 87.E CITY /_ , , STATE CA ZIP 14c-6 rt / 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 JOAQUrN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: /}, �� --- �! DATE: /D S PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILL/NG 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 provided to me or my representative. - TYPE OF SERVICE REQUESTED: F J\/ED COMMENTS: SAN JOAOUINENT L� HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #:3ypp— DATE; ASSIGNED TO: / EMPLOYEE #: ?j DATE: 71 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: ' Amount Paid �3t S Paym nt Date Payment Type Invoice # Check # 33L4 Received By: