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SAN JOAQUIN COUNCY ENVIRONMENI'Al,HEIALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY 10 p SERVICE REQUEST# <br /> 4::�o <n� 0 <br /> 01YNEli/OPERATOR cHeex if u�❑ <br /> r 'r lY1 � <br /> F�cltiry NAME <br /> SrrE ADDRt:sS 9r750 14 Tho< <br /> HOME Or KAIUNG ADDRES,5f Different from Site Address) [3u �Om �Y <br /> S nftr <br /> 1,rI <br /> CITY C STA'@ � A ZIP <br /> PitONE d1 a(4 - 7(;a V� APN# LANG USE APPtJCATIort f7 <br /> PWME#2 LlJ + EXT. DOSDISTRIer I.oCAnOt►cam <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CNrcKif Bitm4o ADOR��D <br /> Bry <br /> USINESS NAMETacosPHONE <br /> A, <br /> L Li <br /> HOME Or.MAILING ADDRESS FAX <br /> v, ( 1 <br /> CITY STATE 0V ZIP c� <br /> &UILM,G ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or nuthorized agent of same, <br /> acknowledge that all site and/or project specific ENWRo\'rIE\rrAL HEALTit DEPARTNIEwr hourly charges associated with this project <br /> or acth ity will be billed to me or my business as identified on this form. <br /> I also ccrtify that 1 have prepared this application and that the work to be performed will be done in accordance with ail SAN JOAQUIN <br /> CouNw Ordinance Codes,Standards.STATE and FEDERAL laws. <br /> I� 1 c /< I <br /> APPLICANTS SIGNATIIRE:,`�� ;I� T Q r eJ _ DATF: j2 oa 0 <br /> PROPERTY/BUSMUSOWN'ERIN OPERATOR/ItIANAGF.R ❑ OrHF,RAim iowzmAGFN-r <br /> IfAPPIJGNr!isnot the Bl1 LGyG PARTY proof of authorization to sign is required Title <br /> AMOICIZATION TO RELEASE INFORMATION: When applicable,1,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 emrirvnmenLil/site assessment <br /> information to the SA,�,JoAQuw COUNTY ENVIRONNIENTAt.HEALTii DEPAR RiFNT as soon a5 it is available a �t same time it is <br /> provided to me or rrty rt presentative. <br /> TYPE OFSEwcEFttouiisTm: Mobile food facility plan review VE <br /> JACOINA1t7ir5: <br /> saN N 05 2021 <br /> JOA CpUN <br /> HEgCTy p Aroe T.4L <br /> AccEPrEoBY: Vidal Pedraza ErrtPLOym#: 6213 DATE: 1-5-21 <br /> Ass1GNEDTO: Kadeanne Linhares EwLOYEEO: 4589 DATE: 1-5-21 <br /> Date Service Completed (if already completed): SEIMCE CODE 523 P f E: 1601 <br /> Fee Amount: 456 Amount PaloPayment Date <br /> Payment Type � Involve# Check# 1`$ Z FfeeAtecl By: <br /> EHD 48-02-M Payment confirmation# 118469240 SR FORM(Golden Rod) <br /> REVISED 11117/2003 r 5p <br />