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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �vh,afo � Z CHECK If BILLING ADDRESS 13l� BUSINESS NAME Pae FACILITY ID # MAY 2 6 2021 SERVICE REQUEST# HOME Or MAILING ADDRESS ^ /�®QIIJ/ A)rSTATE FAx# ( ) (fie S120U�3�Lf+ OWNER/ OPERATOR JCA,/t DATE: ,, / 60 Va„L ge'o CHECK If BILLING ADDRESS❑ FACILrrY NAME Ex4169 SERVICE CODE: o SITE ADDRESS �� J czo; qe- J ve 5-�l000 ICItV l„'1 r Street Number Direction Street NametJ 4nvoi Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CIN +cc STATE ZIP C 95at � S e�n PHONE #1 /, ^'j ( ,I ) "I / � EXT. 616 APN # LAND USE APPLICATION # �' PHONE 42 ( ) EXT• BOIS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �vh,afo � Z CHECK If BILLING ADDRESS 13l� BUSINESS NAME Pae -� ao Pe4 MAY 2 6 2021 PHONE#EXT. aoa HOME Or MAILING ADDRESS ^ /�®QIIJ/ A)rSTATE FAx# ( ) CITY ) hd6 GA. 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 FEDERAL laws. / APPLICANT'S SIGNATURE: DATE: 5 Z PROPERTY/ BUSINESS OWNER❑ OPERA MANAGER ❑ OTHER AUTHORIZED AGENT El IfAPPLJCANT 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. PAYAwu* TYPE OF SERVICE REQUESTED: COMMENTS: MAY 2 6 2021 IAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: ��ryryyy/' EMPLOYEE#: VI / 111 V DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: o Fee Amount: 15Z� Amount PaidI l„'1 r Payment Date JC 21n 2� n Payment Type l: 4nvoi 1�5� �2)—f Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)