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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Mobile food trailer <br />FACILITY ID # <br />PHONE# FXT. <br />SERVICE REQUEST # <br />3a <br />OWNER/OPERATOR Karen Tabar <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Kay's Creations <br />SITE ADDRESS 535 1 <br />Street Number <br />W <br />Direction <br />CanCion Ct. <br />Street Name <br />Mountain House <br />city <br />95391 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 EXT. <br />(510) 600-1240 <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ^ . CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# FXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENv[RONMENTAL 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: �CawK 7444T DATE: <br />6/2/2022 <br />PROPERTY/ BUSINESS OWNER® OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILGING 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 JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPARTN ENT as soon as it is available and at ttlO;µµp_e time it is <br />provided to me or my representative. r4 lyj�.� <br />TYPE OF SERVICE REQUESTED: 'V Q -D f&U. `�'r(�aT.\rC1-1�' -�r:/f/ r/ <br />COMMENTS:S'qN J <br />Ntg4 O qNCO M �Y <br />�r1� F/yT <br />ACCEPTED BY: L'R V J"+LGS �.o EMPLOYEE M DATE: 0— j 2-2r <br />ASSIGNED TO: L(Hk-W,✓'`c.S EMPLOYEE#: DATE: &—S <br />Date Service Completed (if already completed): SERVICE CODE: �j23 P/E:/(o0/ <br />Fee Amount: �-s� — Amount Pai �G Payment Date � /ct Z2— <br />Payment Type V ,,A_ Invoice # Check # I `l`�Slo02Z�j Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />