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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Businessor Prop <br />//)AF�tC,�ULITY ID #� <br />SESERVICEREQUEST # <br />CHECK N BILLING ADDRESS <br />�(31`jl'CDRESS <br />OWNER /OPEER, TOR <br />PHONE# <br />E'R <br />HOME or MAILING ADDRESS <br />EMPLOYEEM 6213 <br />CHHECEc K ff BILLING ADDRESS <br />FACILITY NAME / <br />CI <br />SIJEADDRE7 <br />( i_ r <br />1` l r kit <br />:5✓✓ <br />I Payment Date <br />��p� J� <br />Payment Type �; jC <br />Invoice # <br />Check # 12�v10 ;2,3/0 <br />Received By: <br />Street Number <br />Directlon <br />Stree Name <br />C <br />ZI Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Stree) Number <br />Sbeet Name <br />CITY <br />STATE <br />zip ` <br />�r <br />PHONE#1 Eu. <br />APN# <br />LAND USE APPLICATION# <br />' ' <br />M <br />PHONE#Z Ear. <br />( ) <br />BCS DISTRICT <br />LscATION CODE <br />AIIVV✓0A <br />CONTRACTOR / SERVICE REQUESTOR <br />EIV T <br />QED <br />?021 <br />EALTN pEpMENUU <br />TA NTY <br />T MENT <br />REQUESTORt <br />CHECK N BILLING ADDRESS <br />BUSINESS NAME <br />+ e A <br />PHONE# <br />E'R <br />HOME or MAILING ADDRESS <br />EMPLOYEEM 6213 <br />DATE: 3-24-21 <br />FAX # <br />t ) <br />CI <br />PIE: 3602 <br />STATE <br />ZIP OF5(5�9 17 <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 />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, Stan S Are and FEDERAL laws. <br />/ APPLICANT'S SIGNATURE: - DATE' — 7 /J�.,( / <br />PROPERTY/ BUSINESS OWNER❑ PEaATOR/MANAGER OTHER AUTHORIZED AGENT .(JCA <br />1J'APPLtcae'T is not the B1LLLyG PdKTY proo jauikarization 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 REQUEsT,EED: <br />/� `�7,, /' <br />COMMENTS: i l( I`i��Y/ .5% r ! �j <br />lll�ao(,W4 5 7; � I � , ys ) a_u F;, <br />l/rlu- <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEEM 6213 <br />DATE: 3-24-21 <br />AssIGNEDTO: Vidal Pedraza <br />EMPLOYEEM 6213 <br />DATE: 3-24-21 <br />Date Service Completed (H already completed): <br />SERVICE CODE: 523 <br />PIE: 3602 <br />Fee Amount: 304 <br />Amount <br />Pao'30'.D <br />I Payment Date <br />..3 �,� 2/ <br />Payment Type �; jC <br />Invoice # <br />Check # 12�v10 ;2,3/0 <br />Received By: <br />REVISED <br />Payment confirmation # 122662310 <br />REVISED 11/17/2003 y <br />i'D P03Lo011 <br />SR FORM (Golden Rod) <br />