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So�m� a,Jr�e^, lia�o� <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# <br />SERVICE REQUEST # <br />Restaurant <br />7F 0023 S8� <br />ACCEPTED BY: <br />j2 8 �, <br />OWNER / OPERATOR <br />ASSIGNED TO: A r Q <br />CHECK IfBILLING ADDRESS® <br />Yes <br />Date Service Completed (If already Completed): <br />FACILITY NAME EI Jere Taqueda <br />p / 1b0 <br />SITE ADDRESS 3218 <br />West <br />I <br />Grant Line Rd <br />I Payment Data <br />Tracy <br />95304 <br />Street Number <br />Direction <br />By: <br />StmeaNa a <br />Ci <br />Zi Cove <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Strael Number <br />Street Name <br />CITY <br />STATE <br />zip <br />PNDNE#II <br />APN # <br />LAND USE APPLICATION # <br />Pttf�lE i2 _ 02-4EM <br />BDS DISTRICT <br />LOCgTION CODE <br />CONTRACTOR If SERVICE REQUESTOR <br />REQuesTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY 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 />1 also certify that 1 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: 17 IO( I Zo2\ <br />PROPERTY/ BUSINESS OWNER®. I OPERATOR/ MANAGER ❑ OTHER AUTHORfZED AGENT 13 <br />Jf APPLICANT is not the BILLING PARTY. proof of authorization to sign it 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 ENVIRONIr1ENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: Lam) <br />COMMENrs: <br />IAN JOAQUIN COUNIY <br />ENVIRONMENTAL <br />HEALTH MMWMW <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: A r Q <br />EMPLOYEE #: <br />2J t <br />DATE 1 2,-1— L <br />Date Service Completed (If already Completed): <br />SERVICE CODE: O b 1 <br />p / 1b0 <br />Fee Amount: \ S 2 _ <br />Amount Paid qt <br />I Payment Data <br />JLL Z( <br />Payment Type ` pr__ <br />Invoice # <br />99"1" l3 S j Z!531Received <br />By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 ^, ^ _ 54 <br />11 <br />N Is <br />