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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Nutrition Club �Woos 303(/ <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> Linda Fortney and Berlin Lillard II <br /> FACILITY NAME <br /> Jumpstart Nutrition <br /> SITE ADDRESS <br /> 4719 Susl�,eeltLmber I Dimtinn I Quail Lakes DELvet Name Stockt2n 9oae <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 1515 Street Number Siemering Way Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95209 <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> ( 209) 608-2525 <br /> PHONIER Ex. BOS DISTRICT LOCATION CODE <br /> ( 510 ) 504-7004 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> John Jose Larribas/Ana Herrera <br /> BUSINESS NAME PHONE# Ex . <br /> J&A Homes Unlimited ( 916 613-3812 <br /> HOME Or MAILING ADDRESS FAX# <br /> 26870 W. Sacramento Rd. ( ) <br /> CITY Thornton STATE CA ZIP 95686 <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: DATE: 12/14/2020 <br /> i ' <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPARTT 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. P <br /> TYPE OF SERVICE REQUESTED: QtAI -'//D-Od <br /> COMMENTS: \rc OCC/ <br /> �Iec�✓lsu � � aC ( 1, <br /> y 77y a q4 N �� <br /> ACCEPTED BY: ,t^��25�0 EMPLOYEE#: DATE: t' <br /> ASSIGNED TO: P EMPLOYEE#: DATE: I 17 ZO <br /> Date Service Completed (if already completed): SERVICE CODE: 2 0 E:41- <br /> Q/ <br /> Fee Amount: Amount Pai b Payment DateD I ` �7l <br /> Payment Type C_ G . Invoice# / rCoheck# 'l g� -yQ� Receiv d�Byy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Dbt.911 JSZ <br />