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SAN JOAQU... iOUNTY ENVIRONMENTAL HEALTE, APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food Facility <br /> OWNER/OPERATOR <br /> Vitaligent- NorCal, LLC CHECK if BILLING ADDRESS L261 <br /> FACILITY NAME <br /> Jamba Juice#956 <br /> SITE ADDRESS 2821 W March Lane, Ste. C7 Stockton 95219 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) c/o Business Licenses, PO Box 8000 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Monsey, NY 10952 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 952.9617 <br /> PHONE#2 EXT. BODISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jeff Weinstein CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Jamba Juice#956 510 282-8910 <br /> HOME or MAILING ADDRESS FAX# <br /> c/o Business Licenses, PO Box 8000 ( ) <br /> CITY Monsey, NY 10952 STATE 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: "'lmLAA ft DATE: 5/18/15 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERALITHORI"LF.DAGENT® Authorized Representative <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. <br /> TYPE OF SERVICE REQUESTED: �� Coas 6111� pAYMENT <br /> `, <br /> COMMENTS: REd �(ED <br /> JUN 03Z015 <br /> SA ENVIAROMENTCIUIN OALN <br /> ACCEPTED BY: EMPLOYEE#: DATE: E. <br /> ASSIGNED TO: Q �- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (Q P I E: <br /> Fee Amount: )"b Amount Paid A. \3o .op Payment Date �0 -tk5 <br /> Payment Type Invoice# Check# g�'(4�j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />