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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAMEPHpN&# �i 2r��N P�pAYA LAO 9 fll %Rte SERVICE REQUEST # - ExT' 51 - 5rA FA 00kolLAIZ S��u45lp�lS OWNER I OPERATOR Va/N�Ii 5/�Or�U�La CHECK If BILLING ADDRESSO G -[,^ FACILITY NAME n E N PAP A 1 /il t ,Ao (/l1. UT 1 VO SITE (ADDRESS) DATE: ' L y 10 1 r l- Street Number Dlrection Date Service Completed (if already completed): -n Street Name C Zip Code HOME or MAILING ADDRESS (If Different from Site ddress) Amount Paid Payment Date 1 n /' 1. r KJ�r� Street Number Invoice # Street Name CITY .rte STATE G/'A ZIP 1 ` 2- I PHONE#1 Exr. APN # LAND USE APPLICATION # � �V q PHONE #2 Ear. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR VA N r so M 1 L-',/'� V f1 �� CHECK If BILLING ADDRESS BUSINESS NAMEPHpN&# �i 2r��N P�pAYA LAO 9 fll %Rte ao�) - ExT' 51 - 5rA HOME Or MAILING ADDRESS FAx # ACCEPTED BY: CITY _TOL TL-)' `t STATE GA ZIP Iq 15 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. 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 COUNTY Ordinance Codes, Standards, SYPTE and FEDERAL laws. n nn APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/N1,10 AGER❑ OTHER AUTHORIZED AGENT'❑ yfAPPL1CANT is not the BILLING PARTYproof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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. PAYMENT TYPE OF SERVICE REQUESTED: Q C RECEIVED COMMENTS; /\� -„ � � � AUG 2 5 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE M DATE: ASSIGNEDTO: EMPLOYEE #; DATE: Date Service Completed (if already completed): SERVICE CODE: I PIE: JWO2 Fee Amount: I Amount Paid Payment Date Z 2— Payment Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 Qeor?z1oa3 SR FORM (Golden Rod)