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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> (SERVIC&REQUEST_ <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Properly { ,,0U-7 s q )-7 <br /> Pizzeria � l� I <br /> OWNER I OPERATOR CHECK if 91UNG ADOREss <br /> Michael Sheehan <br /> FAcamT NAME PIeOiOgy <br /> $READDRESSpacificAvenue Stockton ZIP 95207Cool <br /> 6627 " ireet ame C <br /> s amw <br /> HOME Or MAIUNG ADDRESS (if Different from Site Address) 1/t/, Sahara AVenU S "tee628 <br /> 4616 - Sheet Number - <br /> CITY STATE Zip <br /> 9102 <br /> Las Vegas, NV <br /> PHONE#1 EXT APN# - LAND USE APPLICATION# <br /> ( 310)237-6204 <br /> EI[T 60S DISTRICT LOCATION CODE <br /> P1wNE#2 <br /> 1 5511237-4366 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK If BILLING ADDRESS O <br /> S G C)rr <br /> SUSIN-= -NAMEwltt- <br /> 'Toi�iv� I.LG (p2 to 5435- 2931 <br /> HOME or MAILING ADDRESS - - FA%# <br /> �o S o A� R� - t-r ''�- 323 t(pzt�i • q z - S'4�� <br /> CITY CASA N f-\ STATE CA ZIP q 11 0 <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 ENVLRONMENTAL 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: , DATE: - <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHERAUTRORtzEDAGEN7.❑ <br /> ff APPLICANT i5 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 t0 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. p <br /> TYPE OF SERVICE REQUESTED: <br /> � � 1 <br /> COMMENTS: �� y s �,.r_ I �_ RECEIVED <br /> Q,r 'I iCA SEP 3 0 2016 <br /> dAN JOAOUI N COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPMTN:_ENT <br /> ACCEPTED BY: � EMPLOYEE#: DATE: +(p <br /> ASSIGNED TO: V Id[L� - YC-lN�. _.. . EMPLOYEE#: DATE: IR/lip <br /> DateServieeCompleted (if aireadycompleted): SERYICECODE: (�,52'1J ,PIE: I(OQ) <br /> Fee Amount: ' OD Amount Paid 02 s (� Payment Date <br /> Payment Type v`S r L.VatfAGh Received By: Z <br /> SR FORM(Golden Rad) <br /> EHD 46-02-025 <br /> REVISED 11/17/2003 <br />