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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ICE CREAM SHOP <br />FACILITY ID # <br />(\e,J.) <br />SERVICE REQUEST # <br />sRavy,062ci <br />OWNER! OPERATOR <br />CHECK if BILUNG ADDRESS <br />FAcitrrY NAME <br />SITE ADDRESS lc( 61_ ( 7 <br />Street Number Direction <br />MO LbV7A)/•/ h6l).Se: 1 ‹b,lAy/ <br />Street Name Street <br />PelOONTAIN 1110 1)% <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 1 0 s5- <br />Street Number <br />M 6 DC,••1 A STizee r . <br />Street Name <br />CITY,...A STATE citt), ZIP 47539 j <br />PHONE #1 Err. <br />( 12.51 /1 4 - 6 2-g 4f <br />APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />‘--P14-il-") /1 /4'1 1-7- It 1 CHECK if BILLING ADDRESS a <br />BUSINESS NAME / L -rTA-A-§c7v - D09-2.-s • PHONE # ( cfc) 9/7 - (5 22t <br />EXT. <br />HOME or MAILING ADDRESS fp S>5.- ',lop c=iv A 7RE---6-7- FAX # <br />( ) <br />CITY p,A <br />i r 10 0/•17A-/1•1 A t ) .5 6— <br />STATE <br />ZIP 1 <br />GLi- q-5-.3ci <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. e <br />APPLICANT'S SIGNATURE: DATE: 04(t2 /2 ,0 7_3 <br />PROPERTY / BUSINESS OWNEREr OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 ptAieoame time it is <br />provided to me or my representative. r <br />TYPE OF SERVICE REQUESTED: .etec.(,-t,i -c-; Si,-A-. 641 l./...,4 7 - 1(.:/t/— <br />COMMENTS: APR 1 n <br />SAN 2023 <br />Qu,, , <br />HEA ZillioNtikZotjN r , <br />DEp,41:7.7•AL mENr <br />ACCEPTED BY: 64, VI/IA.4 GA. EMPLOYEE #: DATE: Ly .... // _ 13 <br />ASSIGNED TO: LA4 tipural..._ EMPLOYEE #: DATE: it — ( - 2-3 <br />Date Service Completed (if already completed): SERVICE CODE: C'-a. 3 PIE: 4/0( <br />A mount Paid# 9 ,8. oC) Payment Date 4 ig/23 Fee Amount:t.t61(.41v <br />Payment Type ex i..1-- Invoice # Check # /6 072_6 /2_ Received By: d27y <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)