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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST CoFEIFE Seo? � OWNER/OPERATOR S^M` U��, `�� CHECK If BILLING ADDRESS FACILITY NAME ��C'RR�UckS Co�FEE SITE ADDRESS �2Q �� L1f\\EC A ]Cc3��'1 arreet Number I Dlrectlon \ Street Name I1 t Clt 1 Zi Code 1" HOME or MAILING ADDRESS (If Different from Site Address)2901 .R� Street Number Street Name CITY STATE l 1� ZIP PHONE#1 j ExT• APN# LAND USE APPLICATION# t� (2-CO 1st PHONE#2 EXT. BOS DISTRICT LOCATION CODE t ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR _VAINOCAL Ccs CHECK if BILLING ADDRESSEI BUSINESS NAME 'V _ PHONE# EXT• k-l1 t \PKl(�\f ssOG ,"F S (3" -11�\- gZ So S HOME Or MAILING ADDRESS FAX# CITY 70 STATE � C� ZIP (�OSQI BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific FNVIRONMt NTAL HEALTH DBPARTMI?NT 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,Slandards,Si-AT and PI: I;ttnt. ws.� APPLICANT'S SIGNATURE:� DATE: I I 20 1 PROPERTY/BUSINESS OWNER❑ ( IF.RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT P A tErJT F012 GTna-V U,cs If APPLICANT i.r not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORNIATION: When applicable,1, 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 n1e or my representative. TYPE OF SERVICE REQUESTED: RA yjWE COMMENTS: REG`ElVED TP A1000 2019 ✓� ` �+ ` L(� Jv Ly(t' lLl IICALJH DEPARrV I.L IY ACCEPTED BY: /,,.rr n{5 EMPLOYEE#: DATE: ASSIGNED TO: �q EMPLOYEE#: DATE: (( ZO Date Service Completed (if already completed): 1 if SERVICE CODE: P/E: J� Fee Amount: , 7 Amount Paid `g Payment Date ?'p Payment Type 4 Invoice# Check# f-#/D�sll 3/5Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 1 111 7/2 00 3 IS