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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM�D SERVICE REQUEST �OM IT Type of Business or Property ILLING CHE\CK If/ BILLING FACILITY ID # COMMENTS: a� C� �L / jADDRESS PHONE # � q)') \7�- %'\--� FAx# ( ) CITY ' 5 OWNER / OPERATOR SEP 19 2019 C� 1 �` \ ' i• CHECK If BILLING ADDRE ( l FACILITY NAME\ �- Ll yl hf Ift SITEADDRESS-�1 MPLOYEE #: DATE: / Date Service Completed (if already completed): / /ip Street Number Direction Streat N e Amount Paid / It Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # J Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # .114V IU A 11 PHON ExT. BOS DISTRICT LOCATION CODE .IJlv]L JLyw- CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ^\I`i CA ILLING CHE\CK If/ BILLING BUSINESS NAME N'(J(( COMMENTS: a� C� �L / jADDRESS PHONE # � q)') HOME or MAILING ADDRESS FAx# ( ) CITY ' STATE ZIP I BILLING ACKNOWLEDGMENT: 1, 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: DATE: PROPERTY/ BUSINESS OWNE66- OPERATOR / AN R ❑ 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 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: v S COMMENTS: a� C� �L / �% VMENT RECEIVED SEP 19 2019 PERMITSAN JOA ACCEPTED BY: yl hf Ift ASSIGNED TO: r MPLOYEE #: DATE: / Date Service Completed (if already completed): SERVICE CODE: 6/ 1 PIE: Fee Amount: ._---a— 2 Amount Paid Payment Date c3 Payment Type Invoice # Check # J Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003