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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />I ype of business or Property <br />FACILITY ID # SERVICE REQUEST # <br />{^I�iOnw11 <br />COMMENTS: Sf`KQF,c.1110r1 FX V -NI -AY <br />'JC)T� <br />;�1` <br />/� 1 r- <br />OW 'T -WD -M\ k(- <br />NGvGi� u N V <br />OWNER <br />ndII/OPER{A� -R}-A <br />& "' �J'I'Sf !"tl� <br />) <br />CHECK R BILLING ADDRESS <br />FACILITY NAME TA ON I -A Ch 1(l({ I RA - <br />-SA Nj <br />0-4Q1j <br />SITE ADDRESS 76.10 <br />Street <br />V <br />Hof THOEPgEN q�N <br />Number Direction <br />HOME or MAIUNGADDRESS (If Different from Site Address) <br />Street Nama <br />SID <br />C a code <br />ASSIGNED To: KadeanneLinhares <br />G��,14 St�T <br />CITY t� <br />TK-Ft�,� <br />et <br />StreNumber <br />Street Nama <br />STAIE '7 <br />(JI <br />PHONE#t Ezr APN # <br />( , sba -,may 3 �e <br />PIE: yo <br />LAND USE APPIJCATION # <br />PHONE#2 <br />( 1_110 -_,SUo Ez (\'t `c�, <br />Payment Type YPe V�Invoice # <br />Cheek #I S / 51 <br />Receive By: <br />BOS DISTRICT <br />LOCATION CODE <br />vlv 1 ]KAU I VX i SERVICE REQUESTOR <br />REQUESTOR Ar-AK]Ar I EE -JA (\W <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME - a. 11A - <br />PM <br />HOME <br />1 PH NE Sb8- 121 E,tr. <br />HOME or DDRESS PAX# <br />CITY <br />TMA k,G STATE CA zip q <br />j� <br />Mr T Mdl w FvwtA�vr .� STI`� <br />�uca„gucu property or D11311IesS 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, Standards, STATE and FEDERAL law. /f <br />APPLICANT'S SIGNATURE:.,��Ls.L�ft7 DATE: 3I LZI Z2 <br />PROPERTY/ BUSINESS OWNERS, OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENTO <br />IfAPPLICANT is not 1heB11.1"GPARTr proof of authorization to sign is required Title <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 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: � Mp kvL OVA <br />1' .n <br />{^I�iOnw11 <br />COMMENTS: Sf`KQF,c.1110r1 FX V -NI -AY <br />'JC)T� <br />;�1` <br />/� 1 r- <br />OW 'T -WD -M\ k(- <br />NGvGi� u N V <br />IN <br />) <br />MAR?3ZO1? <br />-SA Nj <br />0-4Q1j <br />V <br />Hof THOEPgEN q�N <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE #:DATE; <br />6213 <br />3-23-22 <br />ASSIGNED To: KadeanneLinhares <br />EMPLOYEE#: 4589 <br />DATE: 3-23-22 <br />Date Service Completed (if already completed): <br />SERYICECODE:S <br />PIE: yo <br />Fee Amount: 14(;(o Amount Pal <br />Payment Date 3 z u^ <br />Payment Type YPe V�Invoice # <br />Cheek #I S / 51 <br />Receive By: <br />EHD 48"02-025 Payment confirmation 140957131 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />Ir <br />D <br />