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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER j JQ7T# <br /> Food Wagon "Fa K)U 113� 1Z� 1 <br /> OWNER/OPERATOR <br /> Ramon Guerrero CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> T. EI Grullense <br /> SITE ADDRESS S Wilson Way Stockton 795205 <br /> 1331 Street NumberFDirection Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Same Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 740-2844 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ramon Guerrero CHECK if BILLING ADDRESS <br /> BUSINESS NAME P # Exr. <br /> T. EI Grullense �r9 740-2844 <br /> HOME or MAILING ADDRESS FAX# <br /> 1331 S. Wilson Way ( ) <br /> CITY Stockton STATE CA ZIP 95205 <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 bRESas ide tifie on this form. <br /> I also certify that I have prepared thison an tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, nd Fs. <br /> APPLICANT'S SIGNATURE: 2 <br /> �E: DATE: ZO <br /> PROPERTY/BUSINESS OWNERYSI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. w <br /> TYPE OF SERVICE REQUESTED: AY <br /> COMMENTS: <br /> /to <br /> 4141?q1 1 <br /> 0 <br /> h RO UIN CO 0?0 <br /> ryo pMEHT�H1Y <br /> ACCEPTED BY: / r EMPLOYEE#: DATE: 2/) <br /> ASSIGNED TO: I EMPLOYEE#: DATE: v <br /> Date Service Completed (if already Completed): SERVICE CODE: P i f /f;{ <br /> Fee Amount: �' GU Amount Paid 5a Payment Date 1 (/Q✓ <br /> 0 <br /> (2 <br /> Payment Type Invoice# Check# a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 f kl�vv-e75� <br />