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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 4Z^_ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COMMERCIAL KITCHEN/CAFE IN OFFICE SPACE �� �" S� 00.7 Y /_0 <br /> OWNER/OPERATOR Simpson Manufacturing Co. <br /> P 9 CHECK if BILLING ADDRESS <br /> FACILITY NAME Simpson Strong-Tie, Stockton Branch <br /> SITE ADDRESS <br /> 5151 SOUTH AIRPORT STOCKTON 95206 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E r. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> **6L 1 21N N Q CHECK if BILLING ADDRESS <br /> H 'I r• <br /> BUSINESS NAME e nC /1f 1ALCW p so 6'4 PHO ExT. <br /> W # 1 <br /> HOME or MAILING ADDRESS- D FAX# <br /> 4683 CHASOT VIL, 11300 ( ) <br /> CITY <br /> P L 68 SAN TO N STATE C! ZIP Gt 4 rs? <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: DATE: 11. OZ• 2-oft <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablet the same time it is <br /> provided to me or my representative. , <br /> TYPE OF SERVICE REQUESTED: jkcqFI!/ <br /> COMMENTS: V 0 <br /> Full Kitchen for serving a Cafeteria SAN,10 2018 <br /> Fly QUI <br /> HFA y 00�PM �t <br /> ENT <br /> ACCEPTED BY: ,amu-,� e EMPLOYEE M DATE: (2-1 <br /> ASSIGNED TO: �x 1-`2 Y,� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S Z?> P/ ( O <br /> Fee Amount- L �DD Amount Paid L� Payment Date 1 2 l <br /> Payment Type Ll l(�_ Invoice# Check# '�S�•� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />