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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Taco Bell Restaurant -7 ✓I- <br /> 3 <br /> OWNER/OPERATOR rr 1 v <br /> PBCIfIC 68115 CHECK if BILLING ADDRESS <br /> FACILITY NAME Taco Bell <br /> SITE ADDRESS 1100 �� (� Escalon 95320 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR .1/_J; 4r,,,.- a CHECK If BILLING ADDRESS <br /> BUSINESS NAME (\(/( PHONE# EXr. <br /> Pacific Bells 1360 694-7855 <br /> HOME or MAILING ADDRESS FAx# <br /> 111 W.39th Street ( ) <br /> CITY Vancouver STATE We ZIP 98660 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: AC9 11aMAeC� DATE: 3.19.21 <br /> PROPERTY/BUSINESS OWNER 1:1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Construction Project Manager <br /> IfAPPG/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION 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 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. L <br /> TYPE OF SERVICE REQUESTED: ; rY (�I.G.O 4 A/ <br /> `�l <br /> COMMENTS: jC0 <br /> ��aw� Ivl ��) �((t�� MAR <br /> 1s NogQ30?O?1 <br /> Nfq�Tk ON MENpuNTy <br /> ACCEPTED BY: / _.✓rA<-S GO EMPLOYEE#: DATE: E <br /> ASSIGNEDTO: Fa kv EMPLOYEE DATE: 2, <br /> Date Service Completed (if alread completed): SERVICE CODE: PIE:1601 <br /> Fee Amount: q,s � Amount Pai t�G�� Payment Date 3 [� 3 <br /> Payment Type IlkInvoice# Check# '562-09 Receive By: <br /> EHD 025 REVISED 1117/2003 �4,t_Q.�• I� aeLc,� (� �V tv SR FORM(Golden Rod) <br /> 2c�Z <br />