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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST (2-0 75,4 33 <br /> Type of Business or Property FACILITY ID# n SERVICE REQUEST# <br /> CONCESSIONS Z-/ �� S <br /> OWNER/OPERATOR <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 953P4 ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 880 W MOUNT DIABLO AVE. Street NumberT Street <br /> CITY STATE ZIP <br /> TRACY CA 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2^ 3,77- ong <br /> PHONE#T EXT. BOSDISTRICT LOCATION CODE <br /> (925-) f4, 7- 3 9011 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> JERROD LAKEY CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> L209L399-0888 <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 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 at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards E and RAL I S. <br /> APPLICANT'S SIGNATURE: DATE: C7W <br /> PROPERTY/BUSINESS OWNER /OPERATOR/MANAGER KI OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLLVG 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C� „�c� ti -�l t\ PA <br /> COMMENTS: NECEIVEb <br /> FEB 2 12024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Iu.al.T tf D[pARTMENT <br /> ACCEPTED BY: C' ,.c EMPLOYEE#: DATE: r2 2 <br /> ASSIGNED TO: L �, f— EMPLOYEE#: DATE: .-2-�— <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date Z <br /> Payment Type � Invoice# I 9h6c--k# (7-nReceived By: <br /> EHD 4B-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />