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SAN JOAQUIN COUNTY ENVIRONMENTAL 11EALT11 DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> !JO /1106/(! o*ee( u`�7y1QQ6)0%q1q2- <br /> OR <br /> y1n •0 '/), /yam/ ,�t/)�/ CHECKH01Ll1NG ADDRESS <br /> FACILITY NAME J /�,`, 114''I//�'f4'e ,r ✓/ ///W�l'o <br /> SRE ADDRESS ASO /U ( V—�`/.J-'P' <br /> r 1 l��� / ', �J�� <br /> Slreel Numbor D1.e,ln Street W. e ➢ Lotla <br /> HOME or MAILING ADDRESS (N Different from Site Addr a) <br /> 22S' W Street Numbe Name <br /> CRY STATE ^ 7/1 AP qS <br /> PHONE#1 N. E-• APNM LAND USE APPPPUCATION N Z LQ <br /> PHONE#2 E". SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK K BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> HOME or MAKING ADDRESS FAX# <br /> ( ) <br /> CRY STATE LP <br /> BILLING ACKNOWLEDGEMENT: 1, the undcnigncd property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL IIEALni DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form '1 <br /> 1 also certify that I have prepared this application and that the work to be performed will be done is accordance with all SAN JOAQt1IN <br /> CouNt'Y Ordinance Codes,Standards,STATE�a-nndd FrDERAL law�ss..J <br /> APPLICANTS SIGNATURE: ✓ w //rQI/(� 77/O1'-CI DATE: 9. 9 ZDZ/ <br /> PROrFiTY/BUSINESS OWN. F.RI� OPERATOR/MANAGER ❑ OTHER AUTTIORViD AGSM❑ <br /> O'APPIJCAAT is not the 811 LIA'C PARTY proof of authorization to sign is required Title <br /> AUTIIOR17_ATION TO REI.EASE 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, gcotechnical data and/or erlvironmerltallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENvtRONM1xrAL 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: R c <br /> COMMENTS: MPF Plan review C4 <br /> SA SEP O9 ?4?1 <br /> p N110AQU/N <br /> fHFALTy�E A6NO UNry <br /> Rr <br /> ACCEPTED BY: Vidal Pedraza ft <br /> 6213 DATE: 9-9-21 <br /> ASSIGNED TO: Daria Afonskaia 9825 DATE: 9.9.21 <br /> Date Service Completed (H already completed): VICE CODE: 523 P/E: 1601 <br /> Fee Amount: 456 Amount Pal `�S6Payment Date M <br /> Payment Type �.-�- Invoice# Check# /3�`fS�9Z.5 Received By: <br /> EHO 48-02-025 Payment confirmation# 131456925 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />