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1\e\J"-- e CA -e <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Ivlobile, Food Fuci ti i-ii' <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR CHECK If BILLING ADDRESSaj <br />The_ evoyest t`-'intio LI C. <br />FAccrry NAME 'Re r.ve.ve,s4 Mis-Kko <br />SfTE ADDRESS 1, 5 if3S <br />Street Number Direction <br />MMI-C-Ve_11 k_Ct <br />'Street Name <br />5 ClIk- LI ers e_ <br />City <br />9 511 0 <br />Zip code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Orr( STATE ZIP <br />PHONE #1 Err. <br />(409-q11 — eq3 1 <br />APN # LAM) USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />EMAIL <br />e-Ve-YES 6AMO bag /e4i) CI H'1 Oa l'airn <br />BOS DISTRICT LOCATiON CODE <br />CONTRACTOR / SERVIC RE UESTOR <br />REQUESTOR <br />' * 3k(Mtkai, c Oft _ <br />CHECK If BILLING ADDRESS Er <br />BUSINESS NAME <br />The. gvest&i- Ro-mo LA-C. <br />PHONE # Err <br />(408)-9 I 1 - 9 C 61 <br />HOME or MAILING ADDRESS <br />t5 elS NktriNkYt_Li Ra . <br />FAX # <br />( ) <br />Crry STATE c A ZIP cis vio EMAIL <br />e_YelPA&VrIlitibomOq ,nia; I. trhi <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorize ag nt of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br />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. I. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <br /> <br />DATE: kbitBi 'Lb 2_5 <br /> <br />OPERATOR / ANAGE OTHER AUTHORIZED AGENT 0 &le r <br /> <br />If APPLICANT' iS not the BILLING PAR Fr, proof of authorization to sign Is required J Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />reore sentative. <br />TYPE OF SERVICE REQUESTED: FO el a P I CON. C, ke_dt -t-c MciAll if() d -Ek eh i-PAY.N1F NT <br />COMMENTS: ( 1 k f 4,13,,,,,c_. fl,.... VA. y <br />NI ( --,-; ri-cv,1 -, g— <br />RECEIVED <br />NOV 0 1 2023 <br />SAN JOAQUIN COUN - <br />FNVIRONMFNTAI , <br />DAlidEAW E§EtP.A IE N ACCEPTED BY: (ç.-4 .c.....s. c ..... EMPLOYEE #: <br />ASSIGNED TO: C 1-,, i r`..,,.. EMPLOYEE #: DATE: i 0 <br />Date Service Completed (If already completed): SERVIC.ECOOE: t::-/-2, 3 PIE: i & 0 i <br />Fee Amount:A/86 . 00 Amount Paid . , Payment Date <br />Payment Type V /C4A— Invoice # yot f(# 11 .1), 6 i 6s- / Received <br />1 01i <br />END 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />PRost-N2Lo <br />Scanned with CamScanner 5