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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail store - see's Candies S Gov <br /> OWNER I OPERATOR <br /> Richard Escalante CHECK If BILLING ADDRESS <br /> FACILITYNAME see's Candies <br /> SITE ADDRESS 2164 Daniels Street Manteca 95337 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3423 S. La Cienega Blvd <br /> Street Number Street Name <br /> CITY Los Angeles STATE CA ZIP 90016 <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> ( 310 ) 993-9635 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Richard Escalante CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Ext.Sec's Candies 310 993-9635 <br /> HOME or MAILING ADDRESS FAX# <br /> 3423 S La Cienega Blvd ( ) <br /> CITY Los Angeles STATE' 'CA ZIP 90016 <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: ��i DATE: 8/24/20 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER © OTHER AUTHORIZED AGENT 11 Manager of Construction <br /> /f 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 i5 available and at tPTple time it is <br /> provided to me or my representative. !`1 <br /> TYPE OF SERVICE REQUESTED: Plan Check <br /> COMMENTS: <br /> sqNj ?g AZO <br /> HFq Tyo P4 4 Py <br /> It? <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEE 6213 DATE: 8-26-20 <br /> ASSIGNED TO: Gehane Fahmy EMPLOYEE M 8788 DATE: 8-26-20 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: /,01 Amount Paid �OT tq,) Payment Date <br /> Payment Type �J; _ /� Invoice# Check# 1121,6��S Received By: <br /> EHD 48-02-025 �t SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />