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op <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Community Theatre <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />Ghostlight LLC CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Ghostlight <br />SITE ADDRESS <br />1744 Street Number Direction <br />Pacific Ave <br />Street Name <br />Stockton <br />City <br />95204 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crrv STATE ZIP <br />PHONE #1 Exr. <br />( 209) 227-5377 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Craig Vincent CHECK if BILLING ADDRESS <br />BUSINESS NAME Ghostlight <br />PHONE # Exr. <br />( 209) 609-6730 (cell) <br />HOME or MAILING ADDRESS <br />1744 Pacific Ave <br />Fax# <br />( ) <br />Crry Stockton STATE CA ZIP 95203 <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: <br />PROPERTY / BUSINESS OWNEREI <br /> <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT 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: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P / E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />V4;te-ez..#tt- DATE: 7/8/2022 <br /> <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003