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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oUQsS�� S�oc� 303 <br /> OWNER/OPERATOR <br /> Muhammad Luqman CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Shinks Halal Meat&Grocery,1213 E.Hammer Ln,#Y,Stockton Ca 95210 <br /> SITE ADDRESS 99210 <br /> 1213 E.Hammer Ln Stockton <br /> Street Number I Direction I Stnrel Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CIO( Hou)/ Street Number Street Name <br /> CITY l—I o D , STATE C n ZIP 1"� s k�L q 6 <br /> PHONE#f ExT. APN# LAND USE IAPPLICATION# <br /> (209 1 956-6856 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209 ) 570-5277 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � n <br /> Sa I t `C CHECK N BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 J0AQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. ), <br /> APPLICANT'S SIGNATURE: k M L"- V lytt o'-- DATE: /U 2c, 21 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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, 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 C0UNTY 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: T <br /> COMMENTS: <br /> p�T 2021 <br /> t" QUlN CO <br /> Ty pFP ENTgt <br /> /l 7m <br /> ACCEPTED BY: EMPLOYEE#: O DATE: Z' <br /> ASSIGNED TO: ✓1 ,( EMPLOYEEM DATE: 'L/ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: i /Y)7 <br /> Fee Amount: l Amount Paid 6 r--- Payment Date I O IYr� <br /> Payment Type invoice# a �JZ� I a� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Ip�O5�2YSL1 <br />