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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Ty�p/wee/of Busineeass or Prope FACILITY ID # <br />Ott CHECK if t NG ADDRE <br />S/E�RVICE REQUEST # <br />OWNER/ OPERATOR <br />CHECK if BI <br />o DR <br />v S S �- <br />EMPLOYEE#: 6213 <br />HOME Or MAILING ADDRESS <br />FACILITY NAME <br />FA%# <br />CITY <br />SITE ADDRESS () \\ <br />o <br />C <br />Fee Amount: 456 <br />L <br />V <br />V Street Number <br />Dhaetb <br />Sbaet <br />Payment Type T� <br />Invoice # <br />ZI Co <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Rece <br />ed By: <br />Street NumMr <br />vee[ a <br />STATE ZIP <br />� <br />CITY <br />SR FORM (Golden Rad) <br />EXT. <br />APN# <br />LAND USE APPLICATION# <br />PNONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />rnNTRACTOR / SERVICE REOUESTOR <br />REOUESTOR 1� / <br />Ott CHECK if t NG ADDRE <br />Buswl=ssNAME t <br />' <br />Sci C <br />PHONE. EXT. <br />"G <br />i� L�U S <br />v S S �- <br />EMPLOYEE#: 6213 <br />HOME Or MAILING ADDRESS <br />9-21-20 <br />FA%# <br />CITY <br />STATE Zip <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 <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 F�aws. _ %C% 7 <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNERt� OPERATOR i MANAGER ❑ OTHER AUTnORIZED AGP.NT ❑ <br />I,fAPPLICANT is not the BILLINGP4RIT Proof Ofauthor&Afi0n to sign is required Title <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 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 N V� <br />.Y�_�t � I <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Vehicle Dlan check <br />�:SAF jC) ? ?p?0 <br />N ��l4 IN c <br />FA�THa ���,o, Nry <br />ACCEPTED BY: Vidal PedraZa <br />EMPLOYEE 6213 <br />DATE: <br />9-21-20 <br />ASSIGNED TO: Vidal PedraZa <br />EMPLOYEE#: 6213 <br />DATE: <br />9-21-20 <br />Date ServiceCoritpleted (if already completed): <br />SERVICE CODE: 523 <br />PIE: 1601 <br />Fee Amount: 456 <br />Amount Pai <br />�,S , �� <br />Payment Date <br />q <br />Z0 <br />Payment Type T� <br />Invoice # <br />Check # ��Z (Q 71 <br />Rece <br />ed By: <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />� <br />SR FORM (Golden Rad) <br />