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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Food Trailer <br />FACILITY ID # SERVICE REQUEST # <br />SQZ(b8(0 4 L2. <br />OWNER! OPERATOR <br />CHECK if Aaryn Jones BILLING ADDRESS <br />FACILITY NAME <br />A Little Taste of Culture <br />SITE ADDRESS 445 <br />Street Number <br />N. <br />Direction <br />Lafayette 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 Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(209) 814-2554 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Eier. <br />( 510 )414-0106 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Aaryn Jones CHECK if BILLING ADDRESS <br />BUSINESS NAME A Little Taste of Culture PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS <br />445 N. Lafayette ct. <br />PAX # <br />( ) <br />CITY <br />Mountain House <br />STATE Ca ZIP 95391 <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 />Verrfietl by pcIfFIller <br />APPLICANT'S SIGNATURE: 00_1- e-s_ D TE: 5/9/2023 <br />PROPERTY / BUSINESS OWNERRr OP RATOR / MANAGER 0 OTRER AUTHORIZED AGENT 0 Owner <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 DEPARTMENT as soon as it is available at same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 01- -Gtel 40t-C (I a-- <br />..... • %,... t. / 101E7) <br />COMMENTS: c(e <br />it/14 Y 0 0 <br />Y <br />2023 <br />JOA He-'AIVIR QUIN c Ao-H 0/vivi .A ,OtiN Ty <br />t*PA fij-A „,r4,..1. 'pito. <br />ACCEPTED BY: Ca V ivt- 4S. c-C.:-) EMPLOYEE #: DATE: i.:;-- -01 - 23 <br />ASSIGNED TO: Ca.. r r- e-.5 c...-c, EMPLOYEE #: DATE: sr--1 —2.-- <br />Date Service Completed (if already completed): SERVICE CODE: 5,1_,3 PIE: 1(0 0( <br />Fee Amount: 4-Le s,: Amount Paic 17 4-4,70D Payment Date 571 /23 <br />Payment Type c frtati._ Invoice # Check # /6/ /375-3.7_17 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003