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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # En. <br />SERVICE, REQUEST # <br />FAX# <br />CITY STATE zip <br />COMMENTS: <br />Sc R <br />RETAIL FAMILY CLOTHING STORES <br />RETAIL FAMILY CLOTHING STORES FOOD INSPECTION <br />FOR FOOD AREA <br />OWNER/ OPERATOR <br />BURLINGTON#1440 5308 Pacific Avenue#1000 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HF N QUI <br />Sherwood Center (BURLINGTON COAT FACTORY) <br />SITE ADDRESS <br />I <br />I <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 6213 <br />5308 Sveet Number <br />Direction <br />PACIFIC AVENUE Street Name <br />DATE: 10-18-22 <br />STOCKTON city <br />zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P I E: 1601 <br />1830 ROUTE 130 NORTH Street Number <br />AmountftY.�g, Ob <br />Street Name <br />CITY <br />STATE zip <br />BURLINGTON <br />NJ 08016 <br />PHONE#1 En. <br />APN # <br />LAND USE APPLICATION # <br />( (609) 387-7800 <br />N/A <br />PHONE V En. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # En. <br />HOME or MAILING ADDRESS <br />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: 444"f DATE: 10/13/2022 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />IfAPPLICANT 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. An t <br />EHD 48-02-025 Payment 151573447 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />,I r'` <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />`D <br />0C'T <br />RETAIL FAMILY CLOTHING STORES FOOD INSPECTION <br />FOR FOOD AREA <br />R Z�?2 <br />electronic <br />HF N QUI <br />A(TyO p�R'VC <br />"4 <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 6213 <br />DATE: 10-1$-22 <br />ASSIGNED TO: Lydia Baker <br />EMPLOYEE #: <br />DATE: 10-18-22 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 523 <br />P I E: 1601 <br />Fee Amount: 468 <br />AmountftY.�g, Ob <br />Payment Date <br />fb/ ZZ <br />Payment Typeaw ' <br />Invoice # <br />Check # /,S-7,5-73 <br />Recei ed By: <br />EHD 48-02-025 Payment 151573447 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />