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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 90ty 10 <br /> OWNER/OPERATOR <br /> DYMON M. HANES CHECK if BILLING ADDRESS <br /> FACILnY NAME NEXT LEVEL 209 NUTRITION <br /> SITE ADDRESS 4120 N EL DORADO STREET STOCKTON <br /> 95204 <br /> Street Number Direction Street Name Ci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 209) 610-9699 <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear' <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Oymon 94.7fanes DATE: 04/30/2021 <br /> PROPERTY/BUSINESS OWNERXI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IjAPPL1CANT is not the B/LLING 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at a time it is <br /> provided to me or my representative. c <br /> TYPE OF SERVICE REQUESTED: rooc\ C q C <br /> COMMENTS: r7 O <br /> H DL' <br /> ACCEPTED BY: LJ\ C\"(7,(.e_S EMPLOYEE#: DATE: <br /> ASSIGNEDTO: L� /.es EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S Z 3 PIE: b <br /> Fee Amount: y b — Amount Paid �j S � Payment Date j— S' — 2, <br /> Payment Type L L invoice# Check# ReceivedEHD 48-02-025 <br /> By: <br /> REVISED 1111712003 �-^ ` 2 y SR FORM(Golden Rod) <br />