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SAN JOAQUT'_COUNTY ENVIRONMENTAL HEALTF—EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Mobile Food Facility L1 S' Uv 7�� <br /> OWNER/OPERATOR CHECK H BILLING ADDRESS <br /> Vernetta Holland-Lee/ Edward Lee <br /> FACILn NAME NOLA 504 INC dba E & B's BBQ Smoke Shack <br /> SITE Stockton 0 ADDRESS <br /> / �^� <br /> U-�r� �n� < J <br /> r1" Stroet Number Direction me Ci Zi Code <br /> HOME or MAILING ADDRESS (H Different from Site Address) <br /> Stneet Number Street Name <br /> CITY STATE LP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209 481 -9851 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 2091 423 - 8313 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK H BILLINo ADDRJE <br /> 4 Lae- <br /> BUSINESS NAMEAl / /� �/ r r PHONE �/?'-� <br /> /V VL—N ,1-494 fti s ., 1"A f � t, i d[is (L.'I�) /�'v 3 'b ✓� <br /> HOME Or - ^^ore FAX# <br /> a� <br /> CITY STATE Ca LP <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, TATE and L law <br /> APPLICANT'S SIGNATURE: . DATE: 09/07-2016 <br /> PROPERTY/BUsrNESS 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 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. /0+ <br /> TYPE OF SERVICE REQUESTED: e I�I G l Q� S G G fI V r1 CC161,_�Y r <br /> COMMENTS: FP D <br /> tiE8. <br /> roogctt Z�16 <br /> TN oo,TzA ��N� <br /> FNT <br /> ACCEPTED BY: / /i EMPLOYEE#: DATE: <br /> ASSIGNED TO: l• G(�! r) EMPLOYEE#: DATE: <br /> Date Service Comple d (H already completed): SERVICE CODE: PIE: <br /> Fee Amount: '' Qf Amount Pai '3 . z5 d Payment Date <br /> Payment Type Invoice# Check# IDI Rec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />