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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F ood fire e SRO0 <br /> OWNER/ PERATOR _/) I� <br /> Ghri0" ��� /fl/ CHECK If BILLINGADDRESS� <br /> FACILITffAM�F I n L a,/ <br /> SITE ADD Sb <br /> TI (/ i <br /> Street Number Direction Str¢¢t Nam _ CI Zi Cotle <br /> H ME 1tIlAIUNC�ADDRESS (If Different from Site Address) <br /> f L/ L/ c o�r� Cif Street Number Street Name <br /> CIN SQ SAT zip <br /> PHONE#I (� (/�� ` EXT. APN# LAND USE APPLICATION# <br /> (,-to % <br /> ( S`l� Y6Sj <br /> PHONE# EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE�TO� �L"l Lo <br /> _ n <br /> r-_l w � Qir 'c' (� CHECK If BILLING ADDRESS <br /> BUsIt)V6r N E /r��/ n /j�/�-'�_J r C /'.�f PT PHON t /�� ' EXT. <br /> HD moo/ (/(Tr��(A-YCLU(r'S l �,t-� (J o" �", al/'' �1 (Ax# `� <br /> CITY / V( t � ��$T E 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 FEDERA aws. ,'QQy/.]� 1 / <br /> 46 <br /> APPLICANT'S SIGNATURE: 'V, — DATE: r I l <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization to Sign i5 required Title ' <br /> AUTHORIu i0N TO RELEASEE 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 all 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> JAN 13 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIHOMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: t)( 13Lp <br /> ASSIGNED TO: EMPLOYEE DATE: 01 ) 1(0 <br /> Date Service Completed (if already completed): $EP,VICECODE: - cC- � PIE: i1l�O <br /> Fee Amount: 7 ,(J� Amount Paid 1 Payment Date <br /> Payment Type C /� Invoice# Check# I DC7, 2, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />