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s 4 � SAN JOAQUIl&UNTY ENVIRONMENTAL HEALTH_ :ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# FCOA TRk-rk S V- OM 13 �. OWNER/OPERATOR IX CHECK IfNG ADDRESS FACILITY NAME Goc-dos Taco SITE ADDRESS 10 1 L w�e r I OO P-6S .I�- n G520S Street Number Olrectlon Street Name C no Code HOME Or MAILING ADDRESS IN Different from Site Address) 1�Z wQ.y� _10Z) nQC 1 Street Number ,1.• S ttNa�me C1 CITY J` �r STATEC ZIP 9S209 PHONE#I EXT. APN# LAND USE APPLICATION# (20W - 9 PHONE#P Ext. BOS DISTRICT LOCATION CODE ( ) 051 - 12040 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK if BIWNG ADDRESS li enr t BUSINESS NAMEPHONE# EXT. Gnof-' dp s 2CR 851- 8040 HOME or MAILING ADDRESS FAx# W2- i✓ . Uv t- l o v I ) CITY ] -.`-T STATE GA zip gS20S 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 TE and FEDERAL laws. APPLICANT'S SIGNATURE: gz' -- DATrE�:r a^_I-7-I,�-7 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER ADTNOmzED AGENT t71 Atzmr"Tila r,, If APPLIC4NTisnottheStacflVGPAR proof ofauthorizadon to sign is required Title 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: Fool) p COMMENTS: OR TRI sip o 7 Zola a�c��o P 07 209 _�RONIMENT TM CEO NTALHMTH r� HEALTH DEPARTMENT£ PERMITMERVIC ACCEPTED BY: r^ �I ),y EMPLOYEE#: DATE: ASSIGNED TO: vi n V V 1 `�✓ V �/ EMPLOYEE#: DATE: � I Date Service Completed (1 ready completed): SERVICE CoDE: P/E: U Fee Amount: 115W Amount Paid S6 — Payment Date cI L711-7 Payment Type C k< Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11117/2003