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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P 12 Q 5 q 15-7 )— <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast Casual Restaurant 2-,38-3'W5 co�2 —; <br /> Chris Sy TAOWNER/OPERATOR I�1J 2 3� �IIL�J 7 <br /> CHECK if BILLINGADDRESS <br /> FACILITY NAME Fire Wings <br /> SITE ADDRESS 6625 Pacific Ave Stockton 95207 <br /> Street Number Direction Street Name City ZI Cea <br /> HOME Or MAILING ADDRESS (N Different from Site Address) <br /> 9105 Brucevllle Rd#6A Street Number Street Name <br /> CITY Elk GroveCATATE 95758 <br /> PHONE#1 APN# 11 "" LANG USE APPLICATION# <br /> ( 209 ) 242-2869 0T1 LA I 0 ULA <br /> PHO j 6 545-8888 BOS DISTRICT �� LOCATION CODE <br /> q <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR none/just painted wall, and decor. CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EeT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 JOAQU[N <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> 3/25/2021 <br /> APPLICANT'S SIGNATURE: �J DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ® OTHERAumumUZEDAGENT® <br /> IfAPPL1cANTis not theBILLiNGPAKTY 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 soft jime it is <br /> provided to me or my representative. rl <br /> TYPE OF SERVICE REQUESTED: ehl- C� T <br /> O <br /> COMMENTS: <br /> saN APR Og'10 20 <br /> yEA T'PohOEg �YPRTCM <br /> ACCEPTED BY: C .f- � C-d0 EMPLOYEE#: DATE: —'z f <br /> ASSIGNED TO: T lC EMPLOYEE DATE: 1 --24 <br /> Date Service Completed (if already completed): SERVICE CODE: Z� PIE: /Gel <br /> Fee Amount: Amount Paid �S'� ()6 Payment Date Z <br /> Payment Type r Invoice# Check# 1�3 S 8 Z JS3 Recelv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />