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SAN JOAQUUV COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S(�ERVIICEE�RECI EST# <br /> MFF &0 Uf "� <br /> OWNER/OPERATOR <br /> JUAN CARLOS MACIAS CHECK if BILLING ADDREss <br /> FACILITY NAME CHARLIE'S FRUTILOCOS <br /> SITE ADDRESS 2542 EL DORADO ST. Stockton 95206 <br /> Street Number I Direction 1 Sheet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Dttferent from Site Address) 804 FALLEN LEAF <br /> Street Number Sheet Name <br /> CITY MODESTO STATE CA ZIP 95351 <br /> PH0tE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 681-3124 <br /> PHONE#2 Em SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR MARCO MORENO CHKKifBIwNGADDRESS❑ <br /> BUSINESS NAME XPANSION BUSINESS CONSULTING PHONE# E'�T <br /> 209 872-9415 <br /> HOME ormmuNG ADDRESS 2520 CASWELL AVE. FAX# <br /> f 1 <br /> CITY CERES STATE CA ZIP 95307 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: O/C"� DATE: 08/16/2021 <br /> PROPERTY/BOSINEASOWNER❑ OPERn R/MANAGER OrnrER AUTronuzeD AGENT IM <br /> IfAPPLICANTisnot the B GPAx7Tproofofauthorizadontosignisrequired Tftte <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. :plain �• <br /> TYPE OF SERVICE REQUEsro: ,c GPA <br /> COMMENTS: RECEIVED <br /> AUG 16 2021 <br /> SAN JOAQUIN COUNTY <br /> 1 /� ENVIRON ENTAL <br /> S`ACCEPTED BY: '!1 EMPLOYEE#: DATE: � '(� ENT• <br /> AsbiGNED To: ( ' t? EMPLOYEE#: DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: PIE: <br /> Fee Amount• LIS—0 Amount Paid 14 ma - ' I Payment Date 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />