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SERVICE REQUEST <br />EHOO61SR revised 09/04/98 <br />Type of Business <br />Mexican <br />or Props rty <br />Restaurant Parking <br />FACILITY ID # <br />1 <br />z 16 <br />SE ICE REQUEST yy <br />2{� <br />OWNER OPERATORp •Ip <br />St. Johns Episcopal al Church/Owner <br />r�{r <br />BILLING PARTY LY <br />FACILITYNAME Cancun Restaurant Parking Lot <br />SITEADDRESS 342 <br />Sb Numbs <br />N. <br />Hunter <br />Shse Hams <br />FAX # <br />St. <br />Type <br />sults <br />Mailing Address (If Different from Site Address) <br />316 N. E1 Dorado St. <br />CITY Lodi, <br />CIT Stockton, <br />STATE CA IJP 95202 <br />466-5311 W. <br />APN# <br />LAND USE APPLICATION# <br />PxoxE #2 EXT. <br />BOIS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REDDEsToR <br />BILLING PARTY❑ <br />Jim Thorpe Oil, Inc. <br />z 16 <br />BUSINESS NAME <br />PHONE# <br />SPECIAL CONDITION(S) OF APPROVAL❑ OTHER <br />(209 368-6175 <br />MAILNG ADDRESS <br />FAX # <br />P.O. Box 357 <br />20 368-1851 <br />CITY Lodi, <br />STATE CA ZIP 95241-0357 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly chargesassociated with this project or activity will be billed to <br />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 <br />Ordinance Codes, Standards, STATE 4RAFfDERAL laws. A <br />APPLICANT SIGNATURE <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER A/)ff NT v <br />IfAPPticwTismtt)eBwNGPm proofofauthorindon nrs required <br />With all SAN JOAQUIN COUNTY <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY <br />PuRuC HEALTH SERVICES ENVrRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:Q <br />� /� <br />e, - o .;=—J <br />z 16 <br />COMMENTS❑ <br />SPECIAL CONDITION(S) OF APPROVAL❑ OTHER <br />❑ <br />FWOOENT <br />RECEVED <br />AL 2 5 Zoo <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SFFIICES <br />ENVIRONMENTAL HEALTH 0]V1',',1 r, <br />I. <br />INSPECTOR'S SIGNATURE: <br />c R's SI' <br />. <br />D Q <br />APPROVED BY: <br />EMPLOYEE#: <br />Q i <br />DATE: - <br />ASSIGNED TO: <br />EMPLOYEE #: <br />�� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />� %' L_' <br />PIE: d <br />Fee Amount: �� <br />`-� <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Rece yed Sr. <br />