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DATE: OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property e 0 ni fti izc( A L — rizucK -4/.14 FACILITY ID # SERVICE REQUEST # Sl2 008.1`-'1 9 9 OWNER / OPERATOR CHECK if /112 • RANT ( 'r 5 1 &/ 4 14 1115 • /3A+2(2-9A rle.ygi( BILLING ADDRESSED; FACILITY NAME.,, t•-r21 e i-1 (.1 smr TRucK Pvt (NA I-- SITE ADDRESS 2._ 5"-- Street Number Direction Fizyci-1 CAMP 12.44c, Street Name FIzEiVew eArne City 16 334, ZIA Code HOME Or MAILING ADDRESS (If Different from Site Address) 1 7 et e 0 Street Number 171 0 RIPH y pARK_L4/4y Street Name CITY 1—A7- p Ro r STATE ZIP cp. cis- 3i o PH NE #1 Err. 190) 35-5-- 5-7ov APN # 173 — 7‘) -14 LAND USE APPLICATION # PA - 16 002_5-1 PHONE #2 EXT. ( ) BOS DISTRICT t LOCATION CODE a q CONTRACTOR / SERVICE REQUESTOR REQUESTOR 197R . 6 UgF/A/DEg frI,4A/6,,47- CHECK if BILLING ADDRESS BUSINESS NAME riZ gAIC /4 CAMP TRUCK -7-Riri/AIA1- PHONE # (100) 55-5--S700 Err. HOME or MAILING ADDRESS *Witl* i 7 I o a ni a Apply rAgie_wAy PAX # ( ) CITY STATE ,y,.. 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, Standard', STATF d FEDERAL. laws. APPLICANT'S SIGNATURE: PRoprR rv / Bt SINESS OVINE RE/ If A PPLICANT 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. Vrt I IIIIL.IN I TYPE OF SERVICE REQUESTED: 5011- IP ITAmi/7//1// 712,A rE zeAD//44 5T -cay 200 EiV RECEIVED COMMENTS: DEC HEALTH SAN JOAQUIN ENVIRONMENTAL DATE: DATE: tz(e1/ 06 2019 COUNTY DEPARTMENT I g P ACCEPTED BY: v ,i(XJ EMPLOYEE #: ASSIGNED TO: , ....-/ EMPLOYEE #: Date Service Completed (if already completed): SERVICE CoDE: Fee Amount: .Iat) Amount Paid it L O g — Payment Date 12-4 h 7 Payment Type (0) t Invoice # Check # 6) 1 2' 41 Received By: "or - /04 /b khy EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/1 7 /2003