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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS JV� BUSINESS NAME,? � FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS C) - f'- FAX# �.S19-009 /30/ OWNER / OPERATOR `� �C[G�C CHECK If BILLING ADDRESS Sr l • Com' \ J DATE: �� G FACILITY NAME 5+(D c SERVICE CODE: E X 5-5S TE A/ypa� PIE if ✓lf Fee Amount: L IT -�O Amount Paid Gi�-- Pa ment Date y r)I Payment Type tre Number Direction ,�Ul Street Name Clt ZI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE zip PHONE #t EXT. (e3Z) 337 - SII APN # LAND USE APPLICATION # PHONE #2 �) O EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ��7 l CHECK If BILLING ADDRESS JV� BUSINESS NAME,? � „ ,fit rL�) PHONE# EXT. HOME or MAILING ADDRESS C) - f'- FAX# CITY STATE�/j zip 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 FED laws. APPLICANT'S SIGNATURE: DATE: /J PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER El OTHER AUTHORIZED AGEN�J G�rs7-rc(CA7 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. OAVag_ TYPE OF SERVICE REQUESTED: C I f L( ?vL ��i[,► T COMMENTS: PAYMENT RECEIVED r►rZ Z 2019 SAN JOAQUIN COUNTY .- �A-'� r 2019 bQU/N C C�G V/T � �T /' EC01J 7Y ,RTMENT ACCEPTED BY: EM L9 ONMENTAL L CEPA T ENT DATE: (CJ 2 �� ASSIGNED TO: r EMPLOYEE #: DATE: �� G Date Service Completed (if already completed): SERVICE CODE: J L PIE if ✓lf Fee Amount: L IT -�O Amount Paid Gi�-- Pa ment Date y r)I Payment Type Invoice # Check # J ReC@ived By: EHD 48-02-025 REVISED 11/17/2003 U SR FORM (Golden Rod)