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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food Truck S 0 a <br /> OR/OPERATOR <br /> f p 0-0 1 I^,_in <br /> FAAM9 �t CiV �A..y�n I_n /}`✓ CHECK If BILLING AooRESS� <br /> cr NLL`U.it �'f�Gi/I <br /> ( , t n S )I e b5�-e r <br /> SITE ADDRESS 12xPiards blvd SV6y w ' fo 95ai1 <br /> 1100 Street Number Direction Street Name /�,� C ZIPCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 52,r15 0-010190-01019Coy <br /> La l <br /> Street Number Street Name <br /> CITY San 'D1s-�0 STATE ZIP 9211-7 <br /> PHONE#f APN# LAND USE APPLICATION# <br /> (fJ9 ) aq59--2185 <br /> PHONER ExT• BOS DISTRICT LOCATION CDDE <br /> (619 ) 20.5 2550 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Nksln` Mom /r���ler PHONE Ems• <br /> �J J 1M� l{J O"1 C � 59-2185 <br /> HOME Or MAILING ADDRESSW1b lv 52 IJ b n�ryNt. t I l <br /> CITY Cn h '1�)t e* <br /> STATE ( d ZIP 9211 r� <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,PT <br /> .{Ea�n�d FEDERAL laws. Q� <br /> APPLICANT'S SIGNATURE: �{�{�X (7wi1C, DATE: <br /> PROPERTY/BUSINESSOWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLiCANrisnollhe BLLL/NCPAR proof of authorization to sign is required Titre <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 the same time it is <br /> provided to me or my representative. 14Y <br /> TYPE OF SERVICE REQUESTED: VO4 , /`/•C�� C,(C/ <br /> COMMENTS: <br /> AUG <br /> 182021 <br /> SANH�ROUIN COON <br /> HEALTH pE Ty <br /> M NT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I� Amount Paid /sa`v Payment Date <br /> Payment Type ' Invoice# Check# 3627 9,3 Receiv d By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 P��CLv'N I <br />