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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ice Cream Shop <br /> OWNER/OPERATOR <br /> vic%'A( RnoL NO of is CHECK If BILLING ADDRESS <br /> FACILITY NAME V5 <br /> SITE ADDRESS 5 <br /> 701 i , l <br /> Street Number Direction Street Name CI ZI Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 412�21 2.2 Street Number Street Name <br /> CITYe 4 STATE ZIP <br /> PHONE#1 EST. APN# LAND USE APPLICATION It <br /> (q b) ob Z <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> (q Ib) q?,o 61Z (D& <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 5 CHECK If BILLING ADORES <br /> BUSINESS NAME PHONE# EXT. <br /> HOM Or MAILING ADDRESS FAX# <br /> CITY SuCra STATE ZIP <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. <br /> APPLICANT'S SIGNATURE: //l f dG'u t, All <br /> 1� — C. DATE: VS Z I Z I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <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 environmentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. RAYMENT <br /> TYPE OF SERVICE REQUESTED: yDod RECEIVED <br /> COMMENTS: <br /> MAY 2 1 2021 <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE DATE: y_ 7I�7,n <br /> ASSIGNEDTO: flc- '1 EMPLOYEE#: DATE: <br /> -C/�- <br /> Date Service Complet d (if already completed): SERVICECODE: � IE: D3 <br /> Fee Amount: (00Amount Paid L S — Payment Date 2 <br /> Payment Type VLS ---- I I v ice# n)I,Chhock# Received By: <br /> 1 ,�\� <br /> EHD 48-02-025 Y/ `� SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> S <br />