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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyO0UF�I QTY ID# SERVICE REQUEST# <br /> Food Wagon Food Wagon #2 U D <br /> OWNER/OPERATOR <br /> Ramon S. Guerrero CHECK if BILLING ADDRESS <br /> FAciuTYNAME <br /> T. EI Grullense l Jl J <br /> SITE ADDRESS S Wilson Way Stockton 95205 <br /> 1331 Street Number I Direceon Street Name city ZID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE IJP <br /> PHONE#I EXT' APN# LAND USE APPLICATION# <br /> Q09 1 715-8796 <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> 1 ) 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ramon S. Guerrero CHECK If BILLING ADDRESS❑ <br /> BUSINE SNAME PHONE# EXT. <br /> T. EI rullense 209 715-8796 <br /> HOME or MAILING ADDRESS FAX# <br /> (209 )815-9338 <br /> TYnkton ST 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 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,Staya STA and FEDERAL IaI S. PAyAPPLICANT'S SIGNATURDATE: 10/12/20It . RE �%119e�E®PROPERTY/BUSINESS OWNEROPERATOR/MANAGER® OTHER AUTHORIZED AGENT❑JfAPPLICANTiSBILLING PARTY proof of authorization to sign is required Title @CrTT2020 <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the prope94Nl96xe#J Cg <br /> Vim,,,,_„4UNTy <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen�Vpp���R�h��� �^�'PAL <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t E53me P"M NT <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:Food Wagon Inspection <br /> COMMENTS: <br /> Our food wagon is in the shop for minor repairs and we need to bring in the back-up alternate for 2 <br /> days of use to replace the one in repair. The temporary truck is License Plate 5E9315. <br /> ACCEPTED BY: S EMPLOYEE M y b DATE: I <br /> ASSIGNED TO: EMPLOYEE M Cl/tl DATE: 10 '/13 20 <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 . 03 <br /> Fee Amount: S�2- 1 Amount Paid S Payment Date Q <br /> Payment Type Invoice# Check# $ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - <br />