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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> City sports complex/concessions Sfdffl�e;e; <br /> OWNER/OPERATOR <br /> City of Tracy CHECK If F' .INGADDRESSE] <br /> FACILITY NAME Legacy Fields Concessions Stands (soccer fields & westP, . ballfields) <br /> SITEADDRESS 4901 N. Tracy Blvd. Tracy, CA T6�304 <br /> Street Number Direction Street Name Ci. ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 333Civic Center Plaza <br /> Street Number Street Name <br /> CITY Tracy STATE CA Zip ^J5376 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209)831-6201 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Christine Mabry ✓ <br /> CHECK if BILLING ADDRES <br /> BUSINESS NAME City of Tracy (2ExT <br /> 09 831-6201 <br /> HOME or MAILING ADDRESS FAX# <br /> 333 Civic Center Plaza (209 ) 831-6218 <br /> CITY Tracy STATE CA Zip 95376 <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,Standa—l�/nqT--A TP a__—I FPnPp A r laws. <br /> APPLICANT'S SIGNATURE: _ ck ' M*- DATE: 2/26/19 <br /> PROPERTY/BusINESs OWNED OPERATOR/MANAGER ❑ OTHER At1THORIZED AGENT❑ Management Analyst <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, geotechnical 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: eC <br /> wctl <br /> COMMENTS: i JN 4&A S IV FEB 2 <br /> C ?019 <br /> (CC vls S ENViR QUtty cou <br /> N�LTy DEpgR�T <br /> ACCEPTED BY: �r s EMPLOYEE#: DATE: 2 -26 _( <br /> ASSIGNED TO: ���1a A1C S EMPLOYEE#: DATE: 2_2 ^/ <br /> Date Service Completed (if already completed): SERVICE CODE: J�'�3 P 1 E: ('(o 6 <br /> Fee Amount: 6eS-4-:Ov Amount Paid 6g77- <br /> Payment Date �( <br /> Payment Type `-( G 4nvoice# Check yy17633 / Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />