Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant I\' '�` �'(,,--) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> E&A Holdings, LLC. <br /> FACILITY NAME <br /> Fina bV John Surla <br /> SITE ADDRESS 122 W River Road Ripon 95366 <br /> Street Number Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 2998 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Turlock CA 95381 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209 ) 632-2647 315 (��16f� <br /> PHONE#2 ExT. BOS DISTRICTATION CODE <br /> (760 ) 214-4555 c9c77ff <br /> C `- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> JKB Living, Inc. <br /> BUSINESS NAME PHONE# EXT. <br /> Fina by John Surla 632-2647 315 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 2998 (760 )214-4555 <br /> CITY Turlock STATE ZIPCA 95381 <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 HEALTx DEPARTMEN'r 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, ST n ' and FEDERAL laws. Q� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPER R/1 'R ❑ OTHER AUTHORIZED AGENT gCommunity Development Direct or <br /> IfAPPL/CANT 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 <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 HEALTFI DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. Aft"AY <br /> TYPE OF SERVICE REQUESTED: ,, ' ��e/ <br /> COMMENTS: <br /> L16 <br /> OAQUIN <br /> ?3 ?01I <br /> T RDNM COUry <br /> N DEP 4fe <br /> ACCEPTED BY: C �` EMPLOYEE#: DATE: _ 3 <br /> ASSIGNED TO: ` EMPLOYEE#: DATE: c6_ _ <br /> Date Service Completed (if already completed): SERVICE CODE: ��� P I E: �� ) <br /> Fee Amount: Ll t) 0 Amount Paid L�S�p v� Payment Date g 231i <br /> 1 Payment Type �fE Invoice# Check# 372J Received By: <br /> L_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />