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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R 008(o4&q <br /> OWNER/OPERATOR <br /> U �G � P � CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> La "P l a c t t Taqueria a <br /> SITE ADDRESSrA.2� C �.\^��0-�,� \X\ <br /> fie- \—() � l <br /> Street Number Direction vC , Street Name v` city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Zo S CAe,oif7ee L,7 Street Number Street Name <br /> CITY STATE ZIP <br /> L-'d c S' 2 0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 6sfl) 9zi- Y <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQIUE "e �P r,'�C X-f4 r hrr C CHECK if BILLING ADDRESS 1 <br /> BUSINESS NAME —j PHONE# EXT. <br /> L T CI ( der 2 (2cfl 6' Z <br /> HOME or MAILING ADDRESS FAX# <br /> I b S OCv r r ✓� ( ) <br /> CITY Sv STATE C A ZIP 6 <br /> � � � <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: DATE: 03–o v – ?o23 <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, geoteclulical data and/or environmental/site 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. <br /> TYPE OF SERVICE REQUESTED: ` i� <br /> COMMENTS: 06 <br /> H�110, <br /> D UtN CD 3 <br /> T <br /> ACCEPTED BY: —1 M/lf-1v EMPLOYEE#: 1 OQ Q DATE: 3 <br /> ASSIGNED TO: �� C \� EMPLOYEE#: C/ "L1 VV DATE: J?/ aaCo a 3 <br /> Date Service Completed (if already completed): SERVICE CODE: O(0 I P I E: I <br /> Fee Amount: -00 1 Amount Pai Payment Date <br /> Payment Type ` Invoice# Check# 2Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />