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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />DFAClu"NAME <br />Business or Property FACILITY ID # SERVICE REQUEST # <br />PC -,4-,C— ptc s r 5 r ) <br />1 OPERATOR <br />`n 1 E S �(��'�•� CHECK if BILLING ADDRESS <br />AME <br />LIARESS X735 EnStG.tNDt�l 2D (F{Streal Number meMAILING ADDRESS (N Different from Site Address) atmat Icity <br />�,�StreetNumber Street NameLI ni I �t.lS�TELPAPNn OF r Q'tl ` LAND USE APPLICATION # <br />SOS DISTRICT LOCATION CODE <br />REQUESTOR <br />CONTRACTOR it SERVICE REQUESTOR <br />�r1 ,r A 1 � �y ' r <br />` 0-'l -V 1 0 \c-a/{'V CHECK ff BILDNoADDREss <br />BUSINESS NAME ^(\ rr,,'' Ntl SSUC)f,'J S PHONE# f�Ext. <br />HOME or MAILING ADDRESS CC 11(709)+10 GZ <br />5 Q - x'LL FAX# <br />crrr .y(cx l44u rJSTATE ( ) <br />_. cA ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />fic ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />acknowledge that all site and/or project speci <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 Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: (%,r�L,�- <br />DATEry 869 <br />� q / 2 (1 <br />ESS <br />PROPERTY / BUSINONNER❑ OPERATOR/ MANAGER ElOTuER AUTHORIZED AGENT IJ <br />1fAPPuc4yr is not the Bt i I a PARTY Proof of authorization to 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: Plar CIlI'CIC <br />COMMENTS: <br />SEP 0 2 2020 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE <br />DATE' <br />AS SIGNED TO: Victor AC2Ved0 <br />6213 <br />9-2-20 <br />EMPLOYEE M #: 9832 <br />DATE: 9-2-20 <br />Date SerVlce Completed (ff already completed): <br />SERVICE CODE: 523 <br />P/E: <br />Fee Amount: Amount Paid <br />456 <br />j"� _ Payment Date <br />601 <br />Payment Type Invoice ## <br />/ 3 S Z 3 Lfl <br />Received By: <br />EHD 4&02-025 <br />REVISED l l/1T/2003 SR FORM (Golden Rod) <br />