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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# aERVICE REQUEST# <br /> Wholesale/retail restaurant supplies 2-6Z � <br /> OWNER/OPERATOR <br /> RD Express CHECK if BILLING ADDRESS <br /> FACILITY NAME RD Express <br /> SITE ADDRESS 1015 Hammer Ln Stockton 95209 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) N Kraemer Blvd. <br /> 1265 Street Number Street Name <br /> CITY Anaheim STATE CAZip 92806 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 714) 448-3132 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR Heather Mize CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> ADA Architects 216 244-3953 <br /> HOME Or MAILING ADDRESS FAX# <br /> 17710 Detroit Ave ( ) <br /> CITY Lakewood STATE OH zip44107 <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 we 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,S 7;Jan S. <br /> APPLICANT'S SIGNATURE: / / DATE: 4/22/2021 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAG OTHER AUTHORIZED AGENT El Architect <br /> yAPPLlCANT is not the BILLING PARTY Prof of aaihorizatlon 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: Food Facility Plan review YMEN <br /> CONNENTS: ED <br /> 6l{cE�ari tc �(ea^'rt%.- � �� 1> � 1 v.e APR 2 6 <br /> 2021 <br /> SAN JOAQU/N <br /> ALT7AL TyHEHD)EPA N <br /> R <br /> ACCEPTED BY: A✓or(A EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE DATE: Vu vZl <br /> Date Service Completed (if already completed): SERVICE CODE: S�?j P 1 E: <br /> Fee Amount: .i Amount Pai G s&ioD Payment Date L2-I <br /> Payment Type I Invoice# Check# /4'.2Z6Q Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 l�Ro�tc1.311 <br />