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SAN JOAQU[N COUNTY ENVHtONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property Food Stand FACILITY ID# SERVICE REQUEST# <br /> �FJ 000 () .'08 T C �- 4 <br /> OWNER/OPERATOR <br /> Gilbert D. Cortez & Patricia Cortez CHECK if BILLING ADDRESS❑ <br /> FACILITYNAME Hob Nob Hot Dogs LLC <br /> SITE ADDRESS <br /> t Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS Jif fr4rNt IM 6ile.Address) <br /> I IJ4 IV I�Idlll �l. Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> 1408}469-0401 <br /> PHONE ICL 408-829-3418 E-. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Hob Nob Hot Dogs LLC PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> tp �4. Main St. Manteea, EA. 95336 STATE ZIP <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 FEDERt laws. <br /> APPLICANT'S SIGNATURE:Pciti- ll DATE; <br /> PROPERTY/BUSUSESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT El <br /> IfAPPLICANT 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 JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RFCE�VJD <br /> SFp? <br /> ACCEPTED BY: r EMPLOYEE :� <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Competed (If already Completed): SERVICE CODE: P IE: V02- <br /> Fee Amount: Amount Pal /swot) Payment Date 9 <br /> Payment Type l5lti <br /> Invoice Check# Q — Co0 Receiv dBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S, <br />