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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Boba & Ice Cream Parlor 2,O Gci SR pcj ?J. C)iK+ <br /> OWNER 1 OPERATOR <br /> Vy H Vy CHECK If BILLING ADDRESS El <br /> FACILITYNAME Nitro Baba <br /> SITE ADDRESS Pacific Ave Stockton 95207 <br /> 5757 Pacific q, Brae A-130 <br /> treat Num or 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 EXT. APN# LAND USE APPLICATION# <br /> (209)242-1320 <br /> PHONE#2 EXT. BOSDISTRICT {1� n LOCATION CODE <br /> ( } �JJ U L 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carolyn Natividad CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> LDA Partners (209)943-0405 <br /> HOME or MAILING ADDRESS 222 Central Ct FAx# <br /> (209)943-0415 <br /> CITY Stockton STATE CA ZIP 95204 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or autborized 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 1 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: C-'J'n&L";w— DATE:—12/11/2020 <br /> PROPERTY I BUSINESS OWN ER❑ OPYRATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> IfAPPLICRNT is not the BILLING PARTY proof of authorization to sign is required Time <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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENV]RONMENTALHEALTH DEPARTMENT as soon as it is available and�tdot�$�,m,..e time it is <br /> provided to me or my representative. "{ <br /> TYPE OF SERVICE REQUESTED: N[ �(�/LLI� `�G �. . ? <br /> COMMENTS: <br /> I? <br /> {k <br /> lC Y fm t e1Ci Vx •S[1 !L d ti %$A Al <br /> 'LOAQUI <br /> � �°tN� �rypEp� 7Nry <br /> 4'OzLi! <br /> MWNr <br /> ACCEPTED BY: r"V(6GCO EMPLOYEE#: DATE; orf r <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: P I E: 14497 <br /> Fee Amou12.Z-1 � D� Amount Pai 77 �� �� Payment Date 24 <br /> Payment Type Y Invoice# Check# 1113-T 797 Receiv/d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 P�ZU53 V570 <br />