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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# CSERVIIICE REQQUE�ST# <br /> Smoke ShopY�V`) ✓ v ; "/I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Zaher Alzlndanl <br /> FACILITY NAME <br /> Z vape N discount <br /> SITEADDRESS E <br /> 245 Street Number Direction 11th street Street Name Tray q5 oa <br /> HOME or MAILING ADDRESS (If Different from Site Address) Z de <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (415 ) 261-8759 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Zaher Alzindani CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Z vape N discount <br /> HOME or MAILING ADDRESS FAx# <br /> 245 E 11th street 1 ) <br /> CITY Tracy <br /> CSTATE 5376 <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: q!24— DATE: 12/04/2020 <br /> PROPERTY/BUSINESS OWNERp OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT 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: PAYMENT <br /> COMMENTS: RECEIVED <br /> DEC 0 9 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: <br /> ASSIGNED TO: U EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: \S'Z .- Amount PaidPayment Date <br /> S <br /> Payment Type V� Invoice# Check ttOnT#' 1176 6 b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />