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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />Restaurant <br />HOME or MAILING ADDRESS <br />FAx # <br />OWNER / OPERATOR <br />STATE ZIP <br />go M��Ty <br />Sajad Shakoor <br />CHECK if BILLING ADDR SS <br />FACILITY NAME Falafel Corner <br />EMPLOYEE#: <br />SITE ADDRESS 1219W <br />ASSIGNED TO: w y <br />March Lane <br />I <br />EMPLOYEE #: <br />DATE: <br />Stockton <br />95207 <br />Street Number <br />Direction <br />1 P1 E: 16 p <br />Street Name <br />Amount Paid s6 d (� <br />city <br />Zip Code <br />HOME Or MAILING ADDRESSIf Different from Site Address) <br />Invoice # <br />Check # /t>371S-,/,.3 <br />595 <br />Walking Stick Ct. <br />Street Numher <br />Street Name <br />CITY Citrus Heights <br />STATE CA ZIP 95621 <br />PHONE fit Exr' <br />APN# <br />LAND USE APPLICATION# <br />( 916) 620 4065 <br />PHONE #2 Ear. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />. M 0 V-�,V� e�-4 CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />—i�jrrNev 1\4 <br />NE # Exr. <br />PHO ( �r5 <br />'P <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY <br />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 d FEDE laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT WI OWner's EOR <br />IfAPPLLCANT 1s not the BLLLiNG 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 environment site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atzf, time it is <br />provided to me or my representative. RF,II <br />TYPE OF SERVICE REQUESTED: (-I-z�y� <br />(—e,UL1kp�.� <br />vC/� -t <br />COMMENTS: <br />—i�jrrNev 1\4 <br />8 ?�10 <br />li <br />Nv014Qq/At <br />EAGTjy�'C <br />go M��Ty <br />ACCEPTED BY:���.�,�5 <br />EMPLOYEE#: <br />DATE: 7- —ZZ <br />1 <br />ASSIGNED TO: w y <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 15, <br />1 P1 E: 16 p <br />Fee Amount: ��kj — <br />Amount Paid s6 d (� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # /t>371S-,/,.3 <br />Recei ed By: <br />EHD 48-02-028 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />