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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILIITTY,ISD#tn� SERVICE REQUEST# <br /> Smoke Shop 1✓/' l �u(� 2�J <br /> OWNER/OPERATOR <br /> Samer G Alhanash CHECK If BILLING ADDRESS <br /> FACILITY NAME Lodi gift&smoke shop <br /> SITE ADDRESS N Cherokee In Lodi 95240 <br /> 115 Street Number Direction Street Name city Zip Cade <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 /> ( ) 650-430-6084 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Samer G Alhanash CHECK 1f BILLING ADDRESS❑ <br /> BUSINESS NAME Lodi gift&smoke shop PHONE# Ex . <br /> 650-430-6084 <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: =)q�— DATE: 04-29-2022 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> JfAPPLICANP 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 pro erl ed at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviroon ' essment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a same time it is <br /> provided to me or my representative. 2 <br /> TYPE OF SERVICE REQUESTED: .AN�onau�N coutm <br /> COMMENTS: Ur <br /> ecppp eE�ftTMEN <br /> ACCEPTED BY: EMPLOYEE DATE: Z 22 <br /> ASSIGNED TO: EMPLOYEE#: cm <br /> ;1-S DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: O 1 E: <br /> Fee Amount: 5Z Amount Paid S� Payment Date <br /> Payment Type1 5 A_ Invoice# CueEfr�# ( �� yL Received By: <br /> EHD 48-02-025 All 2-q z z SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> VKb 5w Flo <br />