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02.282022 & - 03:25 Pa PSI <br />SRN "MIN WJllr LWILUHENIAL NEn.TN <br />Inky l bill 1011 AVE, <br />SIRAIIII. CA 9S'M <br />ItMIINa NaE: TNL9ml <br />ORDER# 139695186 <br />PAYMENT <br />$UWICL IE ASI OR IEU It... I1b2.00 <br />Wed? <br />WN1I pia IDIAI. UV W <br />ILIIWXIS 411VICL ICT $1 4" <br />IDIa ".. IM qk <br />PAM e. illi NLMd <br />rnrnxl: well [flip 14M.M. ITNrxI <br />Kill. Mwk <br />Mill, It 4W91 <br />254 IMI; Ib.,...., d <br />CYN. Ilk '41, aDilMl. <br />AIA: aAk1AW,glbb, <br />ANw. l it J BllHiglal ql <br />ANANI. 11',',48 <br />._.----... (ANN AlwAii ll ... <br />.. r.nmu....vu....•....nnun.... <br />AMOUNT PAID: <br />4155.48 <br />1Icml.k Iwy <br />,QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />r' <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK 11 BILLING ADDRESS <br />FACILITY ID <br />PHONE# En. <br />SERVICE REQUEST It <br />916 649-7515 120 <br />FAX # <br />1810 <br />( 916) 649-7511 <br />STATE CA Zip 95820 <br />EN19y <br />hz <br />i.. <br />Stet � Sa Mnto DA 95825 <br />CHECK IT BILLING ApURE55 <br />ACCEPTED BY: <br />I ' � f•�•C <br />�� <br />EMPLOYEE #: <br />DATE: %Z- 2-Y -,Z,? <br />Louie Avenue <br />w <br />Lodi <br />95240 <br />Date Service Completed (N almady completed): <br />S�t NameCI <br />PIE. <br />Fee Amount: <br />Zip L d. <br />YDt from Site Addlase) <br />Payment Date 22_ <br />Payment TypedkgJ <br />��- <br />invoice <br />bIa HYTbIr <br />Rece ey: <br />St,W N.me <br />STATE ZIP <br />ESI. <br />APN a <br />LAND USE APPLICATION s <br />e>R• <br />BOS DIS ImcI <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK 11 BILLING ADDRESS <br />EC <br />PHONE# En. <br />ti <br />916 649-7515 120 <br />FAX # <br />1810 <br />( 916) 649-7511 <br />STATE CA Zip 95820 <br />;EMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />Vor project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />e or my business as identified on this form. <br />ared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />0 r finance Codes, 3Yandards, S��1 <br />STATE and FEDERAL laws. ) <br />APPLICANT'S SIGNATURE: ��(. m Q•5LVU-P_ DATE: 3f /Lax <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER IM OTHER AUTHORIZED AGENT 13 <br />IfAPPLICAxT is not the BILLING PARTY. proof of authoriladon to sign is required Titre <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaUsite 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.A <br />TYPE OF SERVICE REQUESTED: its l <br />EC <br />COMMENTS: <br />ti <br />FB <br />1810 <br />EN19y <br />hz <br />ACCEPTED BY: <br />I ' � f•�•C <br />�� <br />EMPLOYEE #: <br />DATE: %Z- 2-Y -,Z,? <br />ASSIGNED TO: <br />w <br />EMPLOYEE#-. <br />DATE:7_-1j� <br />Date Service Completed (N almady completed): <br />SOME CODE 0� � <br />PIE. <br />Fee Amount: <br />i Z <br />Amount Paid /S� ba <br />Payment Date 22_ <br />Payment TypedkgJ <br />��- <br />invoice <br />Cheek# �9 <br />Rece ey: <br />EHD 4842-025 <br />REVISED 11/17/2003 <br />I <br />SR FORM (Golden Rod) <br />