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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> `Food �re(� C®�lrlrss� Mt7Pu FA DCA 5R00 N - 72 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS13 <br /> FACILITY NAME 1 <br /> SITEADDRESS 1rr �1 r-, S . r-O I�V-t \ 6� S.'�-- ,�i i-pn L?S"ZQ5 <br /> 7Street Number Direction Street Name CIN ZI C de <br /> HOME or MAILING AQDR�ss:( _ ifierent from Site Address) <br /> 9 S Gou Y 1T Street Number Street Name <br /> CIN S- ,Oc(_ 1 STATE /'� ZIP <br /> PHONE#1 EXr• APN# LAND USE APPLICATION At 7 r <br /> 9,09) 8 995 <br /> PIIONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR 1k , <br /> REQUF..STOR \ O r—q `e. CHECK If BI LLI NG ADDRESS L.r <br /> BUSINESS NAMEPHONE# _3. El, <br /> gg5 <br /> HOME Or MAILING ADDRESSp ^ (� FAz# <br /> J Com-( —t 't�- &—.— ( ) <br /> CITY li^d-b3L STATE ZIP <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 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,STATE and FEDERAL laws. -/ query <br /> APPLICANT'S SIGNATURE: /0E: K ri70r,.A a f�lr a ((N. DATE: <br /> a OZ✓� /� <br /> PROPERTY I BUSINESS OWNER PERATOR/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, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmentallsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Q swffafid` <br /> COMMENTS: FEB 2 4 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> 1 `f HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I� <br /> ASSIGNED TO: EMPLOYEE#: DATE: a 1 elf <br /> Date Service Complete (if already comple ed]: SERVICE CODE: �O� Pf E: �2 <br /> Fee Amount: V '(,,Amount Paid 6 V Q U I Payment Dated a <br /> Payment TypeC� Invoice# Check# Received By:2 <br /> l <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />