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IRSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> )REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAcILmNAME Commissary EI Gallo <br /> SITE ADDRESS I South Sacramento Street <br /> Lodi 95240 <br /> 1301 Sheet Number I Direction Street Name city ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1301 South Sacramento Street Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi Ca 95240 <br /> PHONE#'I '• APN# LAND USE APPLICATION# <br /> (209 ) 334-2573 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Julio Rodriguez CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> Triple J <br /> HOME or MAILING ADDRESS FAX# <br /> 3358 Gina Dr ( ) <br /> CITY Lockeford STATE Ca ZIP 95237 <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 3&L4e-/9 <br /> PROPERTY/BUsrNESs OWNER❑ OPERA R/MANAGER IJ 0 OTIIERAUTHORIZED AGENT❑ <br /> 1fAPPLICANTis not the BILLINGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 Aartte time it is <br /> provided to me or my representative. M^Y <br /> TYPE OF SERVICE REQUESTED: C, <br /> COMMENTS: Submit Plans � iI c �r1 <br /> % �qR 05 <br /> ?0,9QU/NMtw�Ft <br /> COUIV <br /> MTMFNT <br /> ACCEPTED BY: � /t�y� EMPLOYEE M - DATE: fq <br /> ASSIGNED TO: (A4 EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SLP/E: O <br /> Fee Amount: K5 Amount Paid 560� Payment Date S <br /> Payment Type Invoice# Check# 9737/2—/f Rec ived By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />