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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILMY ID# SERVICE REQUEST# <br /> Limited Food Serv. [� S� �J�R' <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS ✓ <br /> The Honey Baked Ham Co LLC <br /> FACILITY NAME <br /> HBH California, LLC <br /> SITE ADDRESS 6530 Pacific Ave Stockton 95207 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3875 Mansell Road <br /> Street Number Street Name <br /> CITY S76TA ZIP <br /> Alpharetta X177 <br /> PHONE#1 EZ . APN# LAND USE APPLICATION# <br /> (678 ) 966-3225 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Colette Watlington CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PE><r. <br /> The Honey Baked Ham Co LLC 66-3225 <br /> HOME or MAILING ADDRESS FAx# <br /> 3875 Mansell Road ( ) <br /> Cm Alpharetta STATE GA ZIP 30022 <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: CWatlington DATE: 09-06-2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTnLIC. Supp. Spec. <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required u 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. PAYME <br /> TYPE OF SERVICE REQUESTED: E� <br /> COMMENTS: 2022 <br /> litensesuppc - C hbl� c� �m 1 mNEFENVIRON <br /> LTN DERWNTZ <br /> RTMEN1 <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 9-6-22 <br /> ASSIGNED TO: Lydia Barker EMPLOYEE#: 9818 DATE: 9-6-22 <br /> Date Service Completed (if already completed): SERVICE CODE: 062 1 E: 1602 <br /> Fee Amount: 156 Amount Paid �S i Payment Date -L)j <br /> Payment Type V l Invoice# Check# Received By: <br /> EHD 48-02-025 payment 149472412 �L (P/-,7v v L SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />