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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Amazon SJC7 0Uw:� <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Canteen Vending <br /> ❑ <br /> FARmazon SJC7 <br /> SITE ADDRESS 188 Mountain House Pkwy Tracy <br /> Street Number I Direction Street Name CII ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) L Lia �%l I,I G�I, <br /> Street Number G `�/USlreetName <br /> CITYr�/� STATE ZIP I <br /> M Y <br /> PHONE#1 EXT. QpN# D USE APPLICATION# <br /> Wit) 12 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Canteen Vending CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Canteen Vending P209E# EXT. <br /> 529-5350 <br /> HOME or MAILING ADDRESS FAX# <br /> 542 Mariposia Rd ( ) <br /> CITY Modesto STATE Ca ZIP 95354 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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. G� <br /> APPLICANT'S SIGNATURE: DATE: Iz/ G <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ® OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Thle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment info ion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It IS provided <br /> my representative. kto <br /> ��T <br /> TYPE OF SERVICE REQUESTED: -) A 10 <br /> ��® <br /> COMMENTS: <br /> doq ®l9 <br /> N�Ty O%,41 ASA <br /> qRr FNT <br /> ACCEPTED BY: ' ry EMPLOYEE#: DATE: qIci <br /> ASSIGNED TO: v` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: j Cil <br /> Fee Amount: Amount Pai T; Payment Date <br /> Payment Type � Invoice# Check# Receiv d y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />