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Ci <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST F A o � Z -'�'�� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FOOD 12A I E 1 0 5V <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> SIS (NA <br /> FACILITY NAME r U I ` UP �-t I n_ FP <br /> 1 V,1 IT G U \ . 'L S <br /> SITE ADDRESS Y 4 VvC + ,.y� Ll 7,6 <br /> VStreet Number Dlrection Stree Name 1 YL �� 21 Code <br /> HOME or MAILING ADDRESS (If Different from SiteAddress) <br /> 2Y1 \ I CA ` V C Street Number Street Name <br /> CITY A R �1TF� 0 <br /> S15 <br /> � y t 3 3U <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> (20q) q19 2292 <br /> PHONE#2 ExT. ROS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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. ��7l,, <br /> APPLICANT'S SIGNATURE: _ DATE: P/11 1120 2 2. <br /> PROPERTY/BUSINESS OWNER OPE /MANAGER ❑ OTHE THORIZED AGENT❑ <br /> If APPLICANT is not the B LING 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 at die same time It is <br /> provided to me or my representative. �L <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> ` COMMENTS: <br /> AUG 01 2022 <br /> SAN JOAQUIN COUNTY <br /> Qw <br /> ' ' 1 ENVIRONMENTAL <br /> COVAM HEALTH DEPARTMENT <br /> ACCEPTED BY: J I EMPLOYEE#: q�6 36 DATE: f ZZ <br /> ASSIGNED TO: EMPLOYEE#: YM DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: UP I P I : / Q3 <br /> Fee Amount .UV I <br /> Amount Paid Payment Date SW <br /> Payment Type U 15 A- Invoice# ck# / ( 2,6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />