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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITYID# SERVICE REQUEST# <br /> Fast Casual Restaurant <br /> OWNER/OPERATOR <br /> Provident Horizons,LLC CHECK If BILLING ADDRESS KMpa <br /> FACILITY DAME <br /> Squeeze Burger <br /> SITE ADDRESS 856 WT-Benjamin Holt Dr. Stockton 95207 <br /> Street Number I Direction Street Name CRY Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 3013 Edgeview Dr. <br /> Street Number Street Name <br /> CITY Modesto SZIP <br /> Ca 95355 95355 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 595-3854 N/A N/A <br /> PHONE#2 Ecr. EMAIL BOS DISTRICT LOCATION CODE <br /> (209) 556-2120 t.duncan@sbcglobal.net N/A N/A <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> N/A CHECK if BILLING ADDREss13 <br /> BUSINESS NAME N/A PHONE# T <br /> N/A <br /> HOME or MAILING ADDRESS N/A FAx# ) N/A <br /> CITY N/A STATE N/A ZIP N/A EMAIL N/A <br /> BILLING ACKNOWLEDGEMENT: 1, 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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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: DATE: 5-23-2023 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Member <br /> /f 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 above site <br /> address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment inf e <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is provided NT <br /> representative. E <br /> TYPE OF SERVICE REQUESTED: -Rod C,m5W �vu J <br /> COMMENTS: G 3 <br /> - JOAQUIN CO <br /> EIVVIROIVM <br /> Request for Change of Ownership Only ��LTF/EPgR 0TME TY <br /> NT <br /> ACCEPTED BY:CfA EMPLOYEE#: DATE.C-1 2S 12- <br /> ASSIGNED <br /> ZASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: IV612- <br /> 0101 <br /> Fee Amount: I CJ Amount Paid I Payment Date <br /> e712-3d Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />