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APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 dI<ER AUTHORIZED AGENT 0 y DATE: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property kilo /7e Food Tr t.‘ t k FACILITY ID # SERVICE REQUEST # SCZOTB(c C-ciE OWNER! OPERATOR 5. , re.ve__ 144,v ar-a CHECK if BILLING ADDRESS FACILITY NAME kt/i4"40-1/1/ 1 ir - 1.. l._. co- Xeet amber Direction Cif4,--- Zip Code SITE ADDRESS 4,?.... Plit"€CIP.117et.eee ame -7- I HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Err. ( ) APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) Em41L . • , Win 'fin/ 1-XV€114ned e r 14401/ / BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE RE UESTOR REQUESTOR 4.5- Teive- frP/4/(ra CHECK if BILLING ADDRESS BUSINESS NAME 4w, PHONE # Err. HOME or MAILING ADDRESS07 — ?:,1^- f.PCOK.•••- 404141:4‘..--- Ce": FAX # ( ) CITY -7-4444/ ZIP 9539.9_ EMAIL ..fcii-i BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT 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, Standards, ST and FEDERAJ4awS. Ma, a2- 0 If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 me or my representative. TYPE OF SERVICE REQUESTED: p/(4,. 0 a (ipoLik ) PAYMENT COMMENTS: RECEIVED MAY 0 8 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: -..- .k (,.., ,,,,„, EMPLOYEE #: CiT 0 5" DATE: ASSIGNED TO: V .1 ciati EMPLOYEE #: 6 2 i --z) DATE: Date Service Completed (if already completed): SERVICE CODE: 5 5 Payment Date Fee Amount/46, e, Amount Paid # t g Pli Payment Type \E I 1) Iv Invoice # 911e-a# Le / 5 2 / RS Received By: Title EHD 48-02-025 SR FORM (Golden Rod) 03/22/23