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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> Fast Food Restaurant co 1;)? <br /> OWNER/OPERATOR <br /> Ramon S. Guerrero dba Rasil G. Inc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Tacos El Grullense <br /> SITE ADDRESS S Hunter Street Stockton 95206 <br /> 1320 Street Number I Dlreetion Street Name CIN ZIP Code <br /> HOME or MAILING ADDRESS <br /> ADDRESS (If Different from Site Address) <br /> 1331 South Street Number Wilson Way Street Name <br /> CITY STATE zip <br /> Stockton CA 95205 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209 ) 969-0921 147-170-370 <br /> PHONE#2 EST• BIDS DISTRICT LOCATION CODE <br /> (209 ) 715-8796 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �� CNECK if BILLING ADDRESS� <br /> BUSINESS NAM /�"AEON a PH NE �� 9- �� ExT• <br /> HOME or MAILING ADDRESS FAX III <br /> CITY 771et blV ' PWA C11- zip <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,ST and FEnEa/,g,laws. �y <br /> APPLICANT'S SIGNATURE: L4P8tCO[r� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER O OTHER AUTHORIZED AGENT❑ <br /> IfAPPltG4NT is not the BLLL/NGPARTY proof ofauthorizadon 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/sitem ent <br /> information to the SAN JOAQUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s ptr <br /> provided to me or my representative. ,C t I <br /> TYPE OF SERVICE REQUESTED: f FP o <br /> COMMENTS: 4 JOgQU/ <br /> lyp_ NN ONMeOOUN <br /> DFP NT,g1 <br /> '1 RT'tZ <br /> ll <br /> ACCEPTED BY: !K�/ ' 0. EMPLOYEE#' DATE:'�o cl <br /> ASSIGNED TO: V > v1.1 EMPLOYEE#: DATE: 14 1 <br /> Date Service Completed (if already completed): SERVICE CODE: S Z3 PIE: /� G� <br /> Fee Amount: Amount Paid � Payment Date [� <br /> Payment Type L) Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />