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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sports Bar/Axe throwing cages 0' <br /> OWNER/OPERATOR <br /> Michael Hill CHECK If BILLING ADDRESS x <br /> FACILITY NAME Limitless Axes and Ales <br /> SITE ADDRESS 277 1 Lincoln Center Stockton 95207 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 209 ) 662-4874 09741011 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> Steven Torres, Architect CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Apex Architecture 209 662-4874 <br /> HOME or MAILING ADDRESS FAX# <br /> 735 S. Shasta Ave ( ) <br /> "I Stockton STATE CA Z'P 95207 <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: �9Lt¢2 DATE: 6-3-2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Architect <br /> IfAPPL/CANT 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 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: �I�IA l V' �Wk ' �/,LG"T�`O/'til C- � 4r <br /> COMMENTS: l 0 <br /> cz�cKPlar/nIng (P hof MOAV I cork) ANN0 <br /> saN�oq 3 2021 <br /> NFA QUI <br /> TNDE gRT7-4 MtNTy <br /> ACCEPTED BY: VI EMPLOYEE#: // DATE: (/ -; �-/ <br /> ASSIGNED TO: r { al EMPLOYEE M �3 v� DATE: U47319-1 Q 3 9-I <br /> Date Service Completed (if already completed): SERVICE CODE: ® 5� PIE: I O ' <br /> Fee Amount r1AU Amount Pai IILs- OO Payment Date <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025II "^ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 .t tX <br />