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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 12r54A-44,1-� - t-z4SRw-�zqllO <br /> OWNER/OPERATOR j <br /> ' It°fIM CQnfaAl Vj4ffe✓) 1/1 C CHECK HBILLING ADDRESS[:] <br /> FACILITY NAME T10M tIl D cJ '}1<-7 9 41 o , <br /> SITEADDRESSl2VVtls S MpLY\ SAY' yvirre�rPc/i 95337 _ )s7 WAIWAI f <br /> Street N. <br /> Olr ama C L tl / ` le,—" <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 30 M St eet Number �e 17C�&A��5 <br /> CITY ✓R LOCA STATE C.9 ZIP 0 95- Z <br /> PHONE#t E`T APN# LAND USE APPLICATION# O u4cG! 7YJ <br /> (aVal I LfIb- SISy <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � <br /> 41.4✓1Of9 CHECK IfBILLINGADDRESS <br /> � <br /> BUSINESS NAME p� /fQ_/ 1 , y l�C PHONE# E' . <br /> L. rrT/l V <br /> HOME or MAILING ADDRESS 9 3 ue Pe 'Q O "PI -71 FAx# <br /> l'lt ( ) <br /> CRY ( L./2.\0C-kL STATE C/4 ZIP 953p'Z <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 /> 1 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 Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; OIZ(a/`Z 0 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> 1f APPLICANTisnolthe BILLINGPARYY proof ofauthoriZation Yo sign 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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: Planreview <br /> COMMENTS: ' <br /> D <br /> sqN OCT 28 2020 <br /> JOAQ <br /> ilHEA T/ IVMENO TY <br /> ACCEPTED BY: VidalPedraza . _—`EMPLOYEEM 6213 DATE: 10-26-20 T <br /> AssIGNED TO: Gehane Fahmy EMPLOYEE 4: 8788 DATE: 10-26-20 <br /> Date Service Completed (if already completed): SERVICE CODE: $23 'PIE; 1601 <br /> Fee Amount: 4556 1 <br /> Amount Paid Payment Date ��uo <br /> Payment Type �y Invoice# ' ' diieckYi 160 Reeeiv d.By: <br /> EH048-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> Wea(R-LC\ e Sj �o�/ orn <br />