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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant/Cafe pCW �C)O 'Ga VvS2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> slims noodle bar, LP <br /> FACILITY NAME slims noodle bar <br /> Stockton 95219 <br /> Street Number Direction Street Name Cit Zi Code <br /> SITE ADDRESS 3499 Brookside Road, Suite B <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 969-4684 1��0 2 D l <br /> PHONE#2 EXT. BOS DISTRICT- t F <br /> OCATIOI�CDE <br /> I ) IlJ\V\J U <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sara Elliott CHECK If BILLING ADDRESS <br /> BUSINESS NAME slims noodle bar, LP PHONE# EXT. <br /> 209 969-4684 <br /> HOME or MAILING ADDRESS 3499 Brookside Road Suite B FAX# <br /> CITY Stockton STATE CA ZIP 95219 <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: March 24, 2020 <br /> PROPERTY/BUSINESS OWNER OP TOR/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, 1,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 /6$or a time it is <br /> provided to me or my representative. ��M <br /> TYPE OF SERVICE REQUESTED: hQf'' �V <br /> COMMENTS: <br /> Pd i C-�. S N QVt 4 4V <br /> hEALTH p PgIF �NTY <br /> FNT <br /> ACCEPTED BY: f� t Sc 6 EMPLOYEE#: DATE: 4/ <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E: <br /> V <br /> Fee Amount: Amount Pai 5�,vO Payment Date 2 <br /> Payment Type I ,, I Invoice# Check# l�7���5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />