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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oc)J TrttCK SR00 B7 080 <br /> OWNER/OPERATOR <br /> $S t (a K )a 1i l CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 1 oZ'�1 ` S. S eve n h -s-t. + <br /> -t. Modeo 9 5 3 51 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -70104 E 1 V Or a w a L <br /> Street Number Street me <br /> CITY STATE ZIP <br /> E I K Grove CA q 575-1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510) 8301-g7v7 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> " e r on <br /> % C^1 C ,C Q t r ®L+ CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME `1 T v J J PHONE EXT, <br /> S+ocy'kQna" a Ua1 --7q 09 <br /> HOME or MAILING ADDRESS FAX# <br /> '7 0104 E 1,/ora wad- ( ) <br /> CITY 1 K Grove STATE C/1 ZIP Cl 5-?5 7 EMAIL <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 activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this a licat n and that the work to be performed will be done in accordance with all SAN JOAQUIN' <br /> COUNTY Ordinance Codes, Standards,ST E an FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE; a• 1. 24 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT t9 S t'lce. owner - <br /> If <br /> wnerIf 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 proper ) ated at the above site) <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site ar"Iro <br /> � tion to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same tlmme or my, <br /> representative. L f <br /> rizly <br /> TYPE OF SERVICE REQUESTED: foodVehicle T e GTI 0 / 2U <br /> COMMENTS: H EN ORONM COUIV7Y <br /> EALTM DePgR Ole <br /> NT <br /> ACCEPTED BY: 'T, C a r r u e S C O EMPLOYEE#: DATE: a- i _ a 4 <br /> ASSIGNED TO: JG, 'F,3 h m EMPLOYEE#: DATE: 9 - 1 -a g. <br /> Date Service Completed (if already completed): SERVICE CODE: m(0 I P 1 E: W 0 3 <br /> Fee Amount: I( (D a. � I <br /> Amount Paid ((�2,— Payment Date 21 l 12Lf <br /> Payment Type Invoice# Check# J Received Byuor <br /> EHD 48-02-025 SR FORM(Golden Rod) ! <br /> 03/22/23 pi�os I�q 2 g S <br />