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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property t n Fr91I�D# Z 2 9 S�RVIt�^E\REQUEST cog <br /> OWNER/OPERATOR 1—t l7 ,T/�/ IJLJ <br /> Frank Teixeira CHECK H&CLING ADDRESS <br /> FACILITY NAME <br /> Fagundes Bros Quality <br /> SITE ADDRESS S Jason St Manteca 95336 <br /> 142 Street Number 0IM99n I SIraetName City ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Simet Name <br /> CITY STATE ZIP <br /> PHONE#1APN# LAND USE APPLICATION# <br /> ( 209 )239-0184 <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> John Wall CHECKRB LING ADDRESS <br /> BUSINESS NAME Fagundes Street BBQ LLC PHONE# Ex. <br /> 209 1 2394184 <br /> HOME or MAILING ADDRESS 142 Jason St FAX# <br /> 1 1 <br /> CITY Manteca STATE CA ZIP 95336 <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 /> 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: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER OTHERAUTHORtzED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY Proof of authorization t0 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 environmentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at thFsame time it is <br /> provided to me or my representative. AY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 0 �WVtQ1L 0 JUN 2022 <br /> VIRQQU/N CQU <br /> N�4LTl11) "'ZNZAL <br /> ACCEPTED BY: _ EMPLOYEE#: DATE: 1-21Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: L <br /> Date Service Co pieted (R already completed): SERVICE CODE: P/E: <br /> Fee Amount: JZ Amount Pa 1S� Payment Date -, 2Z <br /> Payment Type Invoice# Check# If 7133L3 I Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P�,�y540ZZ <br />