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j= SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> 'Mow- (50 Sa ww2fo25 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME r. <br /> SPavtos PuvK E=n-s �^,II Gam/ <br /> SITEADD cc- ' ��vc 61l/Ul <br /> r <br /> ?)s 2, 451reel Number Dlrectio ��rSlree N me ^ City Zip CoOde <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY S / � STC/a-.ATE ZIP <br /> PHONE 41 EXT• # LAND USE APPLICATION# <br /> (OWq 1518 9(Q3 7]261 '5APN Fuqglk <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> /�f ,_[t_� y-t6 J_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME it O{.(/ PHONE# EXT. <br /> ev au� (90 88- 9386 <br /> HOME or MAILING ADDRESS r FAx# <br /> 5 2 (NP S'15'— M/ <br /> CITY L'' _ ,l 1 STAT ZIP 95-368 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codex,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4 A"111 DATE: R/d7/ L <br /> PROPERTY/BUSINESS OWNER OP'RA'Z'OR/MANAGER ❑ OTHER APnuoi IZEO AGENTe / <br /> s(�S U Cell fI/bJ� <br /> ifAl'PLICANT it not the BILLING PARTE proofofoHthoriz(ttioa to siglt is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to nic or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: jz/ kfkeV '00d, vpdaTe yatle1n), <br /> mf <br /> ACCEPTED BY: Vida) PedIaza EMPLOYEE#: 6213 DATE: 9-21-20 <br /> ASSIGNEDTO: Vidal PCdraza EMPLOYEE#: 6213 DATE: 9_21-20 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 3602 <br /> Fee Amount: 304 Amount Pai �u Payment Date 9 �D <br /> Payment Type •50� Invoice# Check# f,3 eceiv d 13 <br /> EHD A&02-025 v SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />