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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �1+00070-T3 �� �U079ags <br /> OWNED(OPERATOR .. <br /> {J Y��\ E� • �,���� ,_.._...�—. .y._-.�__._.�___- CHECK If BSLLING ADDRESS <br /> FACILITYNAME <br /> SITE ADDRESS �G1Q W rn�� <br /> _e Street t�um6er Direction I , Street Name �e� City- _ M_Zi OCode <br /> HOME MAILING ADDRESS (if Different from Site Address) <br /> ,�_,___•_ ., _ _�Stroet T Street Name �__ <br /> CITY ;.vTATE�` ZIP <br /> PHONE#1 EXT. APN!j LAND USE APPLICATION# i <br /> 32 q� 6 <br /> PHONE#112 EXT, SOS DISTRICT LOCATICN CODE <br /> CONTRACTOR/ SERNTICF, REQUESTOR i <br /> REouEsro <br /> N-y' CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT* <br /> o <br /> 7---7 Cjrd 329 ->.I$U6 <br /> (TOME or FAILING ADDRESS FAX# <br /> CITY it STATE i✓j� ZIP q sD jl 6 <br /> BILLING ACKNO,'4fLE€GEMEKIT: 1, 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 Or <br /> 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 TATE and FEDERAL laws. <br /> AFPLECANT'S SIGNATURE: i, t`r�� DATE. L �O <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and ail results, geotechnical data and/or environmental/site assessment information <br /> 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 f <br /> my representative. j <br /> TYPE OF SERVICE REQUESTED: Food Su lt-clU <br /> COMMENTS.' RECEIVED <br /> JUN'2 3 2016 <br /> SAN mAQUIN COUNTY <br /> ENVIROMENTA <br /> � <br /> AGCEPTEDBY, jYV1 q ry }�,A !\ Et•,,PLOYF:P#: A (Rn �TIrl� <br /> ASSIGNED To: O t C V-Z EMPLOYEE#' DATE: o <br /> L} ✓ Y/ <br /> Date SarOl r-Compieted (if already completed): I SERVICED SG()(g t PIE, ' <br /> Fee,Amuunt: 110 Amount Paid 3D —�P ymunti)ate 41Z2 i� — <br /> Payment Type � Invoice# Check Received By: <br /> EHD 48-02-025 5R FORM(GoS od) <br /> 07/17/08 <br />