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Feb. 11.2020 3:11PM ST LUKE CHURCH 209 948 2841 No.6663 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />•FACILITY <br />type of Business or Property <br />BUSINESS NAME <br />ID# <br />HOME or MAILING ADDRESS w <br />SERVICE EQUEST# <br />A-4 <br />L( r. <br />COMMENTS: <br />{fid L' y c rid. t <br />DO <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />12020 <br />1 2020 <br />FACILITY NAME <br />SlreAooaEss <br />„ ME <br />7 !1® „ gttt�r <br />Ci r,(-,& -C S C •, <br />SI��iG-(�� <br />�•`r Y <br />Ilea wnber <br />Direo on <br />.J tT 4V SVeel Nem <br />DATE: Z—(( -').p <br />Cil <br />Code <br />HOME or MAILING ADDRESS <br />(IT Different from Slle Address) <br />r <br />AmouG} <br />5-0. � <br />Amount Paid <br />� <br />G'�C%C{„U ) Street Ndmher <br />;1-1 11 a0 <br />slreel Name <br />CITYS <br />Check # <br />STATE ZIP <br />PHONE 41 <br />Em <br />APN# <br />LAND USE APPLICATION if <br />PHONE#2 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR s- /,' SG^ �r�I�y`r 1. . )04- I CHECK if BILUND ADDRESS <br />t L <br />BUSINESS NAME <br />PHONE ba En- <br />iq b —' <br />HOME or MAILING ADDRESS w <br />FAY.# <br />CITY STATE ZIP <br />M <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 HF,ALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this farm. <br />I also certify that I have prepared this application a d that the work to be performed will be done in accordance with all Sant JOAQUIN <br />COUNTY Ordinance Codes, Standards, TAT dE AAL laws. ��""�� <br />APPLICANT'S SIGNATURE: DATE: I4 U <br />PROPERTY /BUSINESSOWN&n pFRATOR NAGER❑ OTHER AOTHo1uzED AGENT <br />IfAPPOL Cd ix nor i e BILLIm2 proof of authorization to sign is required rille <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 environmental1site assessment <br />information t0 the SAN JOAQUIN COLDNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is <br />..Idol.—. nr my ranrecenrative. <br />,..- .-----------_.., . -, --- <br />r <br />r�A <br />YMpAl <br />TYPE OF SERVICE <br />REGUESTED: f� e LJ <br />} <br />COMMENTS: <br />{fid L' y c rid. t <br />c <br />/r��PA <br />elve <br />" `�Lelver- <br />c <br />12020 <br />1 2020 <br />ENVIIR0 UIN <br />�UN <br />„ ME <br />ACCEPTED BY: <br />Ci r,(-,& -C S C •, <br />EMPLOYEE #: <br />DatE: Z _ 1 _ RTMENT <br />ASSIGNED TO• <br />A[: e– "r. C. <br />EMPLOYEE #: <br />DATE: Z—(( -').p <br />Date ServiEompleted (if already Completed): <br />SERVICa CODE: 15 <br />PIEtFee <br />AmouG} <br />5-0. � <br />Amount Paid <br />Payment Date <br />;1-1 11 a0 <br />Payment .Vpe <br />Invoice # <br />Check # <br />Received By: <br />EHO 4"2-025 CD -n SR FORM (Golden Rod) <br />REVISED 1111712003 <br />