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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID N SERVICE REQUEST M <br /> Food business 261899712-0000 SRmm8-4Q,m$ <br /> OWNER/OPERATOR Yaneth Lazcano <br /> CHECK if BILLING ADDRESS <br /> FAcwTY NAME e- C) 5 0l r, <br /> V <br /> Mis Delicias Ta uerja � <br /> SITEADDRESS 3Z0. N aglee ro ste Tracy 95304 <br /> Z0. umber Direction trNl me city Zip Code <br /> HOME Of MAILING ADDRESS (H Different from Site Address) 6b Hanson l n <br /> Street Number _ Street Narm <br /> CITY Brentwood STATE C A PPZIP 94513 <br /> PHONE Nt Brentwood 1/V EErr. APN# LAND USE APPLICATION 0 <br /> (925) 3838571 <br /> PHONE N2 Ext. EMAISOS DISTRICT LOCATION CODE <br /> 925)6646779 Ylazcan0088@gmail.com <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK M BILLING ADDRESS <br /> BUSINESS NAME PHONE M E"t• <br /> HOME or MAILING ADDRESS FAX N <br /> ( <br /> CITY STATE ZIP EMAIL <br /> BILLING ACKNOWLEDGEMENT. I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all silo and/or project specific ENVIRONMENTAL HFAI Di DEPARTMENT hourly charges associated with this project or activity <br /> 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: Yuneth Lanano DATE: 12/29/23 <br /> PROM HTY I BUSINI.SS OWNLR,�( OPERATOR I MANAGER 0 OTHER AUTHORIZED AGENT ❑ <br /> it 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 above site <br /> address,hereby authorize the release of any and all results,geotechnical data and/or envlronmentaVsite assessment information to the <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It is provided to me or my <br /> representative. <br /> TYPE OF SERVICE REOUESTEO; ��('� C t7�(\ �C T <br /> COMMENTS: IZZT <br /> sAN JAN 10 <br /> ?O?4 <br /> OA Qu <br /> HFA ry o p E O OVTy <br /> 4 L <br /> MENT <br /> ACCEPTED BY: EMPLOYEE N: DATE: <br /> ASSIGNED TO: O\(e EMPLOYEE N: L-( S DATE: ( — L'J—2 <br /> Date Service Completed (If already completed): SERVICE CODE: O b I P/E. 1pQ2 <br /> Fee Amount: $1(.2. Quo Amount Pal �6.2•OL) Payment Date 1 — j — Z\,4Payment Type � _ Invoice# Check g 7 70( Sj7 Teceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 C <br /> J <br />