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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY Oil' SERVICE REQUEST# F�ni0 SD`6 pp7900/lo OWNER/OPERATOR vtj nv� CHECK if BILLING ADDRESS FACILITY E 7 U 5 tt-T i4V 8 SITE ADDRESS y 55 6 t plCif' street Number Direction StreetCdame Ci Zi Cotle HOME Or MAILING ADDRESS (If Different from Site Address) N P h1 n e� Street Number stye tName CITY_ / G STATE ZIP PHONE#t/Vvi'/lr/ ES� APN# 2-q8 - 61700 1 LAND USE APPLICATION# O � 3 � 1 PHONE#Z E%r. BOS DISTRICT LOCATION CODE G CONTRACTOR/ SERVICE REQUESTOR REQUESTOR j QuAr/KCHECK If BILLING ADDRE$ BUSINESS NAME U SUS r PHONE# Z- EXT. HOME or MAILING ADDRESS FAX# CITY STATE Z P j 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,S-TATE and FEDERAL laws. '�^ APPLICANT'S SIGNATURE: lGof/✓[ DATE: PROPERTY/BUSINESS OWNER ERATOR ANAGER ❑ OTHER AUTHORIZED AGENT ❑ ffAPPL1CAMKt the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 DkYlda[Ltnme Of my representative. , '.'' N TYPE OF SERVICE REQUESTED: COMMENTS: rpq U 2018 rOAQ „ DE NT ACCEPTED BY: EMPLOYEE#: DATE: - I I V ASSIGNED TO: FI hl-5ch EMPLOYEE#: DATE: iv Date Date Service Completed (if already completed): SERVICE CODE: PIE: C-a Fee Amount: �G' �U Amount Pa' Payment Date 0 / / C Payment Type Invoice# Check# / �2_ Receiv d By: EHD 48-02-025 SR FORM Golden Rod 07/17/08 ( )