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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 71 FACILITY ID # SERVICE REQUEST # Sid oou3q OWNER I OPERATOR CHECK If BILLING ADDRESS FACILITY NAME 4V ` , b ' %trm,n s # Ea Oq b9-4398 HOME Or MAILING ADDRESS SITE ADDRESS t905a ahaelNumber Dlracaan �/ ptress 9 -LW SlreetName r LOd' Cil CITY sabkk QST ZI Coda HOME or MAILING ADDRESS (If Different from Site Address) Street Number Sheet Name EMPLOYEE#: 6213 CITY STATE zip PHONE#1 Ea. l ) APN# . Fee Amount: 304 LAND USE APPLICATION# 36q. OD PHONE#2 Ea. l ) Payment Type ' 5a-- HOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR S CHECK If BILLING ADDRESS urn ado SEP 2 2020 BUSINESS NAMEPHONE TY Gia Ma ou� s SAN JOAQUIN # Ea Oq b9-4398 HOME Or MAILING ADDRESS FAX# J IV'J'ONL lids l CITY sabkk STATEC A ZIP 9S3&8 DATE: 9-24-20 ASSIGNEDTO: Vidal Pedraza BILLING ACI(NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, aclarowledge that all site and/or project specific ENVULONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to we 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 FERE laws. APPLICANT'S SIGNATURE: (,&/V ie . DArE: / �t'''' PRGPERT'Y/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAITTRommDAGENT❑ -S41e'r I AQ)'Mt 111" rffle� If APPLICANT is not the BILLING PARTY proof of aliihol'i$atlott to sigh is required I 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. PAYAfl=i tr TYPE OF SERVICE REQUESTED; .CCE' VED COMMENTS: SEP 2 2020 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: Vidal Ped.raza EMPLOYEE#; 6213 DATE: 9-24-20 ASSIGNEDTO: Vidal Pedraza EMPLOYEE#: 6213 DATE: 9-24-20 Date Service Completed (if already completed): SERVICE CODE: 523 E: 3602 . Fee Amount: 304 Amount Pai 36q. OD ,�P((I Payment,Date Z'C Z�j Payment Type ' 5a-- Invoice # Check # I , Received By: i EHD 48-02-025 REVISED 11/17/2003 Vk 3�o5;1 SR FORM (Golden Rod)