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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (A- O N I -9 NzwiX (oqLkILl <br /> OWNER/OPERATOR <br /> Ramon Guerrero CHECK if BILLING ADDRESS© <br /> FACILITY NAME <br /> I FI <br /> SITE 1W <br /> Wilson Wary Stockton CA <br /> jS��l Street Number Direction treet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 740-2844 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ramon Guerrero <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME T. EI Grullense PHONE# EXT. <br /> 20 740-2844 <br /> HOME or MAILING ADDRESS FAx# <br /> CITY Stockton STATE CA ZIP 95205 <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: �" '�' DATE: 7/11/2023 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ President <br /> If APPLICANT is not the BILLING 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 DEPARTMENT as soon as it is available and PXe time it is <br /> provided to me or my representative. R <br /> TYPE OF SERVICE REQUESTED:Consultation AEb <br /> COMMENTS: 11 <br /> Mobile food truck was previously permitted in SJC. SAN�oq ?023 <br /> 'Y41- Ho pM�CO� NTy <br /> TMFNT <br /> ACCEPTED BY: MUCO EMPLOYEE#: 9828 DATE: 07-11-2023 <br /> ASSIGNED TO: M uro EMPLOYEE#: 9828 DATE: 07-11-2023 <br /> Date Service Completed (if already completed): SERVICE CODE: 1 603 P E: 061 <br /> Fee Amount: $162 Amount Paid /�j�0(� Payment Date "� ��/23 <br /> Payment Type V _ Invoice# Check# �(��X73 /P�(p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />