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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Go -S .S 4 ori $ Food Matt- <br />FACILITY ID # <br />U �` 1 <br />� �1 <br />SERVICE REQUEST # <br />J �-Q C✓ <br />OWNER / ,OpPERA <br />Fr'i <br />OR ` / <br />Fory - �5 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME G <br />1s, <br />ASSIGNED TO: <br />ITEADD(,j/;SS <br />I C/ Street Number <br />(+ <br />1$eorlon <br />a) <br />ee a <br />May).�-e-Cq <br />CN <br />'� <br />9S 33' 9- <br />ZIP Code <br />HOME or MAILING ADORES (If Different from Site Address) <br />a6el W� <br />Street Number <br />Street Name <br />CDy e C /'l ^ g S 3 S 4 <br />STATE ZIP <br />PHONE *' E` APN # <br />(yid 6�-Ll- 46q 6 <br />LAND USE APPLICATION # <br />PHONE #2 Ev. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I�aruyl l maty- S F1a'a'IrY1 q <br />[� `� �/ CHECK if BILLING ADDRESS <br />BUSINESS NAMEC,7\0C1e 1, <br />1��,.� <br />(HONE 6 (� 44 <br />HOME Or MAILINC�.PD RE,$ET /V_ <br />W0. <br />iA7(# ) <br />^ <br />CITY <br />n a 6 S3 STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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, Standar d F L laws. e� <br />APPLICANT'S SIGNATURE: DATE: I — 2 - <br />PROPERTY <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �� 1 C.t/1 tr <br />IfAPPL1CANT 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/s a assessment <br />Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thet�t wit is <br />provided to me or my representative. RMO-.. Nl <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />0ANI 0r <br />CMWSH <br />ACCEPTED BY: <br />ASSIGNED TO: <br />::RIO 010v <br />Date Service Completed (if already completed): <br />Fee <br />Payment Type <br />EHD48-02-025 <br />REVISED 11/17/2003 <br />OU I Amount <br />Invoice # <br />EMPLOYEE#: V fjU <br />EMPLOYEE#: �v ✓✓� <br />SERVICE CODE: o n <br />Payment Date <br />Check # In& <br />2022 <br />DATE: <br />DATE: Z ZZ <br />PIE: 1��8 <br />'?TZ -;'Z <br />SR FORM (Golden Rod) <br />s <br />