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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Rosiness or Property FACILITY ID # <br />s+*S�v IR Sera„ <br />CXEHK ifBIWnG ADoaEaH <br />SERVICE REQUEST # <br />SRON a <br />OWNER/ OPERATOR <br />-Self serve Pe +ro(,p u.wr, IPTG. <br />CxscK'rfRu, wG AanP=_ss❑ <br />FACIurY NAME G--w-ee <br />AGCEPTEDBY: ,t, <br />(6r'o) ST3 - 046 <br />SITEADDRESS 1022 <br />s wmeer <br />Dre Do„ <br />ET 11 <br />Fr-eaugLo r\O�l <br />u exa,�,e <br />EMPLOYEEM —7 Z DATE: <br />a7 <br />Plfron <br />I e' <br />9i 5366 <br />HOME or MMUNG ADDRESS(R Different from SIM Address) 1-O.}� <br />sheet NumEe' <br />e <br />iIF�O r'} QIVGT• <br />Na <br />Payment Date 7/7 Z 7j <br />r <br />CITY Sot" <br />�AX.N 5•nM TT,-MKC'U&� <br />STATE G A ZIP <br />9 4t O gO <br />J'T <br />PHONE#J1 Ett <br />(65V) 588 - 308$ <br />APN# <br />LANDUHEAPP'LIICATON# <br />PHONE#P E>T• <br />( 1 <br />BOS Daimler <br />LOCAr10N CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR 1/3� <br />1� 1 Q 5 yL leS �l'� <br />CXEHK ifBIWnG ADoaEaH <br />BUslNess NAME <br />se -If Serve (eu'. mr-- <br />Commas: ary1 �(tlt,, '•"- w/n� I/�/ r� <br />t J WL. 1-"L+rM 0'J - <br />`J <br />,k <br />PHW1F# P T. <br />16561 4T5 -g3 <br />HOME Or MMUNG ADDRESSFAT# <br />104- fFi rpo v+ 131 vd <br />AGCEPTEDBY: ,t, <br />(6r'o) ST3 - 046 <br />"�,�`"� F <br />C" C 0 wca•, SbVI yxx lL &-5 C-0 <br />STATE L#+ ZIP 94080 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTR 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 S.AN JOAQUIN <br />COUNTY Oidinnnce Codes, S(xnda dt, STAT FEDERAL laws. <br />APPLICANT'S SIGNATURE: ` DATE: 6 //5--/2020 <br />PROPERTY /Blnl.NMOWNEN❑ OPER{TUR/M.WAGERa OTHER AllmoRIZED AGENT❑ Pro+ed- A4Liww <br />If APPUCAbvr is not fire BILLLNGPARTr proof ofouthorizalion to Sign is required • rtrle <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 JOAQL>iA.' COt1NM ENVIRGNMEN rAL HEALTri 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: <br />Commas: ary1 �(tlt,, '•"- w/n� I/�/ r� <br />t J WL. 1-"L+rM 0'J - <br />`J <br />,k <br />t�( (,5 '!1 (?1j <br />�7(V ^' ((Pir1 �.� 1 c'r L-• <br />AGCEPTEDBY: ,t, <br />EMPLOYEE#: u—�f) DATE:'I "J n <br />aL.V <br />ASSIGNEDTO: <br />EMPLOYEEM —7 Z DATE: <br />Date Service Comp tad (If already rnmple d): <br />SERMCECODE: C372Z P E. <br />Fee Amount: Amount P <br />'q,56,,' N <br />Payment Date 7/7 Z 7j <br />Payment Type vi:!' Involca# <br />Check# <br />Pt4e.14ed By: <br />EHO 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />PA <br />RECE vtb <br />JUS 0) <br />SAN'J0AQUI <br />liEAL7- I)&PA TM NT <br />