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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Mobile Food Truck p ?J��u <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> MARGARITA SANCHEZ Email:margaritasnchz@yahoo.com <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Streel Number Direotlon I Street Ne City Zip Cede <br /> HOME or MAILING ADDRESS (If Different from Site Address) Tahoe Timber Way <br /> 2215 <br /> finest Number Street Name <br /> CITY STATE Zip <br /> Riverbank CA 95367 <br /> PHONE#1 Ext• APN# LAND USE APPLICATION# <br /> (209 ) 661-2040 <br /> PHONE#2 EkT• SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> MARGARITA SANCHEZ Email: margaritasnchz@yahoo.com CHECK If81LLINGAODRESS 1-3 <br /> BUSINESS NAME PHONE# En. <br /> Tacos EI Gorda Jay 209 1 681-2040 <br /> HOME or MAILING ADDRESS FAX# <br /> 2215 TAHOE TIMBER WAY (209 )527-6251 <br /> CITY STATE ZIP M67 <br /> RMerbenk CA <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 7 d FED,ErRAA laws. <br /> APPLICANT'S SIGNATURE: 1/l tl DATE: op -9 oa 4 Ca I <br /> PROPERTY/BUSINESS OWNERIM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICANTIsnottheBltuNGPAiz 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. PA x <br /> TYPE OF SERVICE REQUESTED: Plan check R FM <br /> COMMENTS: electronic plans EQ <br /> SAN 10 <br /> Ety vAQUIty C <br /> HEALTH�E gENTq�NTY <br /> ACCEPTED BY: Vidal PedraZa, EMPLOYEEM 6213 DATE: 2-11-21 <br /> ASSIGNED TO: Gehane Fahmy EMPLot'EEM 8788 DATE: 2_11_21 <br /> Date Service Completed (If already Completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: 456 Amount Pai ,Z)D Payment Date rr <br /> Payment Type 'c5Q— Involve# Check# 7 G Receive By: <br /> EHD 48-02-025 Confirmation Number: 120473638 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />