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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME -%eVWi „owl Bar <br />Y` �j•C J.J <br />FACILITY ID # <br />SERVICE REQUEST # <br />(A%# ) <br />CITY CJ.e STATE /'� ZIP �`S� 9 <br />S oo(:Nw7 <br />OWNER/ OPERATOR Lan L14 -He <br />UI C, V <br />CHECK If BILLING ADDRESS® <br />FACILITY NAME <br />Q C MW (1 ,� LJ� y- <br />J <br />SITE ADDRESS , 1 q5 <br />Street <br />I W <br />We <br />A, e <br />l• <br />/•,, <br />Number <br />Direction <br />Street Name <br />CIty <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />gya, <br />Schmidt <br />i E: <br />Street Number <br />Street Name <br />CITY Sto✓-tn <br />F <br />STATE CA ZIP grac)0) <br />PHONE#f ExT• <br />( ) <br />APN # <br />Payment Type- <br />114"1 <br />LAND USE APPLICATION # <br />PHONE#2 Exr <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />`sI. - L 11 tt 1 p CHECK If BILLING ADDRESS <br />1 ,( <br />BUSINESS NAME -%eVWi „owl Bar <br />Y` �j•C J.J <br />PONE# Em. <br />�-i tis -R 1 is <br />HOME Or MAILING ADDRESS �1 rni�1 04— <br />!�1 <br />(A%# ) <br />CITY CJ.e STATE /'� ZIP �`S� 9 <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 F pERAL law . <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNE((a PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />IfAPPL/CANT 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 availsnd at the same time it is <br />provided to me or my representative. _ 'A YMFtiT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS; <br />O ° 202 <br />2SANJAQUINEWI <br />iAL <br />1�COUI)NPALTH ) <br />T VT <br />ACCEPTED BY: <br />�' , <br />EMPLOYEE #: / , <br />DATE: <br />ASSIGNED TO: V ( (j `7 r <br />EMPLOYEE #: �V <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:P <br />i E: <br />Fee Amount:sVe <br />Amount Pal <br />TJb d <br />Payment Date �Z <br />Payment Type- <br />114"1 <br />Invoice # <br />Check # 7J C7'�z (] b <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2005 <br />�IZu,1151I1S <br />