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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail Market <br />FACILITY ID # SERVICE REQUEST ii <br />SlactoNel 2_8 <br />OWNER/OPERATOR I , i_. f , HECK BILLING ADDRESS b On 0-141),.ri r afribk- tin; IM6 1 /11 (,) {-MP:art i) j c if ,....--, ..., r <br />FACILITY NAME Coin fierft (no r1 /11-- <br />SITE ADDRESS 1114 <br />Sireet Number Direction <br />Brookside Road <br />Sireei Name <br />Stockton <br />City <br />CA 95211 <br />Zip Cade <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />C) (e6 vnsicichis 'Or Street Number Street Name <br />CITY t. 1 <br />I <br />, i <br />l i <br />STATE (1 0 ZIP i OC] jr) i <br />7 Q 2 r 1 , <br />PHONE III Ear. <br />(?(-,q) LC (00 -.3sgo APN # <br />110-26-007 <br />LAND USE APPLICATION # <br />PHONE #2 ELY <br />( I <br />EMAIL DOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR TOM Congrave CHECK if BILLING ADDRESSZ <br />BUSINESS NAME University of the Pacific . PHONE ti <br />( 209 ) 946-2541 <br />Err. <br />HOME or MAILING ADDRESS 1050 Brookside Road FAx# <br />( ) <br />CITY Stockton STATE CA ZIP 95211 EMAIL tcongrave@pacific.edu <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 />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAII JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />PROPERTY / BUSINESS OWNER DE1 OPERATOR / MA GER 0 OTHER AUTHORIZED AGENT 0 <br />If APpLichur is not the BILLI.VG PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results. geotechnical data and/or environmental/site assessment information to the <br />SAN JoAoiJIrJ Coutiry ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />representative. <br />PAY Mt TYPE OF SERVICE REQUESTED: 1\.) J._ kik.) tAAP.,•-1e.-0..., RE cE.NED <br />COMMENTS: <br />p (,,p...5 <br />MAI 2 2 <br />2023 <br />tlANTY sr,,,,IECt,(1)tL ENVIR°a N - Itroll <br />HEALTH DEPAR <br />ACCEPTED BY: W -C-. k. _ EMPLOYEE #: DATE: .S---- 7 -,--13 <br />ASSIGNED TO: 1):)--„ k.„..e, ii-L_ EMPLOYEE #: DATE: ,-- f 7 <br />Date Service Completed (if already completed): <br />Fee Amount: ,A (oy Amount Paid <br />SERVICE CODE: _*. 2_ 35_7/ PIE: (06.) / <br />V‘ g Payment Date <br />Payment Type VI it- Invoice # Check it Received By: H.----/ <br />EHD 48-02-025 <br />03/22123 cvt 1222- 2-4 / /2-3 37 I le ( <br />SR FORM (Golden Rod) <br /> <br />ride <br />APPLICANT'S SIGNATURE: <br />DATE: /-/-2-1-z,oz3 <br />PP 02