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S:)c C e <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 1 (Z Q S \-1 'R)CI S 2 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CONCESSIONS -F <br /> 2 <br /> OWNER I OPERATOR 0 J <br /> JAYS GOURMET LIMITED LIABILITY CO CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> LEGACY FIELDS <br /> SITE ADDRESS <br /> 4901 Street Number I Direction I N.TRACY BLVD Street Name TRACY c1tv 95324 ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 880 W MOUNT DIABLO AVE. street Number Street Name <br /> CITY STATE ZIP <br /> TRACY CA 95376 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (7-0)391- 078'8 <br /> PHONE#Z EXr. BOS DISTRICT LOCATION CODE <br /> (92S) A"T 38v 7 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE R <br /> JERROD CHECK if BILLING ADDRESS <br /> ROD LAKEY <br /> BUSINESS NAME PHONE# EXT. <br /> 399-0888 <br /> HOME or MAILING ADDRESS FAX# <br /> 880 W MOUNT DIABLO AVE. ( ) <br /> CITY TRACY STATE CA ZIP 95376 <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 ENvTRONMENTAL 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 at the work to be performed will be done in accordance with all SAN JOAQUiN <br /> COUNTY Ordinance Codes,StandardsE and RAL 1 s. <br /> APPLICANT'S SIGNATURE: DATE: � -Z�s/Z� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT❑ L/i� <br /> IfAPPLICANT is not the BILLINGPARTY,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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: REGEIVED <br /> FEB 2 12024 <br /> !SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALIH DEPARTMENT <br /> ACCEPTED BY: �t f �S c EMPLOYEE#: DATE: a 2 <br /> ASSIGNED TO: L Intl P- f EMPLOYEE#: DATE: Z ZU <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P/E: j Q <br /> Fee Amount: l Amount Paid , a — Payment Date 2,/ !� <br /> Payment Type Invoice# 1 51)u&# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />