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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property n1/41/484•N 4 gOtf-g-Y /f/lAtKr T FACILITY ID # SERVICE REQUEST # C.;Q. DOg(vIS 1-A OWNER / OPERATOR 6A KHA.Multai $R.1 NI VASA KA-0 CHECK if BILLING ADDRESS FACILITY NAME V1JETHA IND/AN SU PEI,MAIMET SITE ADDRESS Z 9 g6 -A i Street Number Number wEST Direction 6 tirwr LINE RD/kat. Street Name _ -MA c-Y City Zio Code HOME or MAILING ADDRESS (If Different from Site Address) i\yA----- Street Number Street Name CITY STATE ZIP I P C PHONE #1 Exr. (570) 689 412.0 APN # 23-860-016 LAND USE APPLICATION # °EC t_9_?a, PHONE #2 EXT. ( ) BOS DISTRICT 3,4)174318NA C ODE 4 1-EnAiviRgnijrii,\/-COL CONTRACTOR / SERVICE RE UESTOR REQUESTOR p` AVID MENA CHECK if BILLING ADDRESS BUSINESS NAME mEN A MC-41(1E4s PHONE # ( 650 ) 2.10 - egoo EXT. MI HOME or MAILING ADDRESS 1175 - • —I, ai— Mitio E C - 4 I--- FAX # ( ) CITY M 1114.N7Ar IN ti 1 g P‘i STATE cA_ zip 904_6 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER 0 OPERATOR / N ANAGER D OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PAR y s roo of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORM ION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: nfitiV afEcK Ver A WA) RivIEV‘ # ArrWALef gerACn Skit( Y • TeA44,44 imirrvvrA44/4* ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 12-19-22 ASSIGNED TO: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 12-19-22 Date Service Completed (if already completed): SERVICE CODE: 523 P/E: 1601 Fee Amount: 468 Amount Paid /./6g....) Payment Date /7 2.2-- Payment Type 6.ed i'-/- Invoice # Check /t I 0343 02 _? fik Received By: EHD 48-02-025 REVISED 11/17/2003 payment 154343029 SR FORM (Golden Rod) 7- Nry DE 7-AL