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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />LLC / GROCERY STORE <br />FACILITY ID # SERVICE REQUEST # <br />s R DA 0 0 a 4 7 <br />OWNER! OPERATOR CHECK if BILLING ADDRESS 132 OASIS LLC <br />FACILITY NAME OASIS ONE STOP <br />SITE ADDRESS <br />2405 Street Number Direction <br />HIGHWAY132 <br />Street Name <br />VERNALIS <br />City <br />95385 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 209 ) 835-1665 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL <br />bookkeepingplustax@gmail.com <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS Fax # <br />( ) <br />Crry STATE ZIP EMAIL <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 or activity <br />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: ADAM M SABA DATE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 12 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING 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 above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />representative. <br />TYPE OF SERVICE REQUESTED: 0 \.,1 /4,_)(\ e (---6•\----s,c c\r-•c.--rn e c,c(-5‘.,--Q --10---9" <br />COMMENTS: "•-• 1 t/ <br />JON , s4A, j <br />24 4fr°410 ' 3 20 <br />111 :414. 2- l'C'0 U/A/ c <br />1.? 1)-11414°U4/1` P4 R7415....7:1 4 <br />ACCEPTED BY: 'L:\ 1,-\\C\CA,C e S EMPLOYEE it: ,_A st c") DATE: . k -3. <br />ASSIGNED TO: TO: -,r-Or-No-VCS EMPLOYEE #: 1 /4-k s,t3c-1 DATE: b, k 3 . z1/41 <br />Date Service Completed (if already completed): SERVICE CODE: 0 b I PIE: t koo 2 <br />Fee Amount: \ ko 2._ — Amount Paid \ \o • 2_ Payment Date QD --- k -_ z Li <br />Payment Type cc Invoice # Check # /g3 57 Received By: aro--- <br />END 48-02-025 <br /> \ S3 oo_ 5- 25-4- <br />SR FORM (Golden Rod) <br />03/22/23 <br />7* <br />OC\ (:)(W_ (\MC