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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REEQUEST# <br /> Restaurant 112- S <br /> OWNER/OPERATOR <br /> Oscar Olais/Ageda Figueroa/Domingo Herrera CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Taqueria Los Altos <br /> SITE ADDRESS E. 11 St racy 95376 <br /> Street Number Direction Street Name City ZIv Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT _J LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Oscar OIaIS CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Taqueria Los Abts ff Y312651 <br /> HOME or MAILING ADDRESS FAx# <br /> 108 E.11 St Tracy,Ca 95376 ( ) <br /> CITY STATE ZIP <br /> Tracy esars <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: Oscar Olais DATE:11/13/2018 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTE;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/sit��►►��++aaysessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the S�ttTr�11 ,,t4y <br /> provided to me or my representativee.' P /V <br /> TYPE OF SERVICE REQUESTED: I V -(A) L,,� `Ll/<3�G t- -- AM <br /> COMMENTS: <br /> V. 201 <br /> C/YIn�O Ull y CO <br /> T•�I10) U MSN <br /> ACCEPTED BY: Ca U t(vi C C) EMPLOYEE#: DATE: (� 7 <br /> ASSIGNED TO: L\. �,r EMPLOYEE#: DATE: l 12 <br /> Date Service Completed (if already Completed): SERVICE CODE: ©� it /E: <br /> Fee Amount: 2- _ ^ Amount Pai D Payment Date 0t� <br /> Payment Typelq Invoice# Ch k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �� <br />