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SERVICE REQUEST# <br />Owner / Operator Hanford Quality Meats, LLC <br />Facility Name I lanford Quality Meats <br />lbSite Address <br />Direction <br />City StateAlameda 94502CA <br />Ext.APN#Land Use Application # <br />999-1221 <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Jeff Weiss <br />Ext.Business Name Hanford Quality Meats, LLC <br />Home or Mailing Address 1151 Harbor Bay Parkwy Ste. 142. <br />94502StateCityCA <br />4/19/2022 <br />Type of Service Requested: <br />Comments: <br />Date:Employee #: <br />Employee#: <br />Date Service Completed (if already completed): <br />Fee Amount: <br />Invoice # • <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />Type of Business or Property <br />Meat Processing <br />Commercial Dr <br />Street Name <br />95304 <br />Zip Code <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />4220 <br />Street Number <br />Home or Mailing Address (If Different from Site Address) <br />Service Code: n-3 <br />Payment Date <br />Accepted By: <br />Assigned to: /—~~)-f <br />Payment Type <br />Phone #2 <br />( ) <br />Phone # <br />( 510) 999-1221 <br />Fax# <br />( 650)581-9493 <br />Zip <br />Check if Billing Address <br />Ph^ne#! <br />1151 <br />Street Number <br />Check if Billing Address S <br />? V7 2__ <br />Received <br />___________ <br />Amount Paid ' - ; <br />| Check# <br />/Yzy-3Zz7^ <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 andLFRDERAL laws. > <br />Tracy <br />City_ <br />1 {arbor Bay Parkway Sic. 142 <br />_____________________Street Name <br />Zip <br />APPLICANT’S SIGNATURE:// UU C7_____________________ Date: <br />Property / Business OwnerE Operator / Manager Other Authorized Agent Il3 President <br />If Applicant is not the Billing 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. Y/Ia <br />Date: <br />P'E: l(D0l