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ME - <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST P vL S`,4 Ip S 8 Z <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Catering Kitchen <br />CHECK If BILLING ADDRESS <br />15s <br />000 <br />OWNER i OPERATOR <br />CHECK if BILLING ADDRESS❑ <br />Kimberl Greenwell <br />FACILITY NAME <br />Upscales Caterinc <br />734-7955 <br />SITE ADDRESS <br />FAX # <br />20677 Golf Canyon Court <br />' -4 -tar Street Number <br />I Direction <br />E Pescader <br />r/�k�me �3\ <br />Tj{ cy <br />ZI c%�e04 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />20677 <br />Golf CanyW&nqurt <br />Street Number <br />CITY <br />sTCa ZIR <br />Diablo Grande <br />95363 <br />PHONE #1 Ex . <br />APN # <br />LAND USE APPLICATION # <br />( 510) 734-7955 <br />PHONE #2 EZT. <br />( ) <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Kimberly Greenwell <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />Ezr. <br />Upscales Caterinc <br />1 519 <br />734-7955 <br />HOME or MAILING ADDRESS <br />FAX # <br />20677 Golf Canyon Court <br />( ) <br />CITY Diablo Grande <br />STATE Ca <br />ZIP 95363 <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 <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,,' STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />�LL <br />/�yypr)r� �y DATE: April 9, 2020 <br />PROPERTY/ BUSINESS OWNERb OPERATO MA AGER ❑ OTHER AUTHORIZED AGENT 11 <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 <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 HEALTH DEPARTMENT as soon as it is available and at theme time it is <br />provided to me or my representative. w � 1-e . _ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: egpe t <br />l�V/Y'4y0 NF°MFg <br />y <br />ACCEPTED BY: Vial Pprlrn7n EMPLOYEE#: 6213 DATE. 4-20-20 <br />ASSiGNEDTO: Kadeanne Linhares <br />Date Service CompWiled (if already completed): <br />Fee Amount: 456 1 Amount <br />Payment Type Vi <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />I Invoice # <br />EMPLOYEE M 4580 DATE: <br />SERVICE CODE: 523 <br />1)7) Payment Date <br />Check# %D <br />4-20-20 <br />PIE: 1601 <br />r <br />ved By: / <br />SR FORM (Golden Rod) <br />S <br />