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I also certify that I have prepared this a <br />COUNTY Ordinance Codes, Standards <br />APPLICANT'S SIGNATURE: <br />and that ork to be performed will be done in accordance with all SAN JOAQUIN <br />FED ws. <br />04 / 0 8 / 2 02 0 DATE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />Raymond Guevara CHECK if BILLING ADDRESS <br />FACILITY NAME La Cabana <br />SITE ADDRESS 5 0 0 <br />Street Number Direction 7th St. Modesto <br />Street Name City <br />, CA 9 5 3 5 <br />Zip Code <br />4 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1 515 Street Number Irwin Ave. Street Name <br />CITY STATE ZIP Es calon CA 95320 <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Raymond Guevara CHECK if BILLING ADDRESS <br />BUSINESS NAMELa Cabana PHONE # 276 <br />Err <br />(209) - 9619 <br />HOME or MAILING ADDRESS 1515 Irwin Ave. FAX # <br />( 1 <br />CITY Es calon STATE CA ZIP 95320 <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 />PROPERTY / BLSINESS OWNER El OPERATOR / MANAGER IEI OTHER AUTHORIZED AGENT El <br />I.f 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 aPAt <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 0/ F2 es <br /> <br />COMMENTS: APR 0 0 <br />4 2020 <br />SA N J04 HEAELAITV4RpQA11-/m/INcorpNrv <br />("EN R 4A, T <br />-- , <br />ACCEPTED BY: EMPLOYEE #: 6, -2„1 i•-!...) DATE: q I 1 2......0 <br />EMPLOYEE #: 1 % 1 X DATE: if. , Lc) ASSIGNED TO: l_....t.,(0,.\. <br />) Date Service Com ted f already completed): SERVICE CODE: (49 I PI E : I t,10 2._ <br />Fee Amount: <br />1 62-- -/S-2. Amount Paid#oD Payment Date Vatio <br />Payment Type Invoice # Check # /071-/-442,1-/-6, Received By: /ID <br />ame time it is <br />Eivr <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003