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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Food <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />Hector Denis CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Taco's Los Austeros <br />SITE ADDRESS <br />650 Street Number Direction <br />Jonquil dr <br />Street Name <br />Lathrop <br />City <br />95330 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />crry STATE ZIP <br />PHONE #1 EXT. <br />(209) 275-8865 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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 T E and FED AL laws. <br />DATE: 9/22/23 <br />OPERATOR/ MANAGER OTHER AUTHORIZED AGENT 0 <br />APPLICAN iS not the BILLING PARTY, proof of authorization to sign is required <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 saite4 ipe it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: , C7--0 e-,( .(c4 <br />4...t...E7 1, <br />r c— if 1 <br />COMMENTS: Skp , <br />s/I N Jo 4 6 202, <br />,c,44 7.„-ToAlm Cou, <br />'IP? rme,--Ai <br />ACCEPTED BY: C- i',,,.es CO EMPLOYEE #: DATE: CI_ 2S— ..—z? <br />ASSIGNED TO: 1071-t 14-<- ,`"" EMPLOYEE #: DATE: q — <br />Date Service Completed (if already completed): SERVICE CODE: 06, ( PIE: /4,049_ <br />Fee Amount: i (i:, --2_, — Amount Paid #1(0.2 . 60 Payment Date 60 77 /23 <br />Payment Type ) i vj 641- invoice # check # /6c-, 371/-332__ Received By: oy6 <br />APPLICANT'S SIGNATURE: <br />!itPROPERTY / BUSINESS OWNER <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003