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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # <br />0 ) <br />SERVICE REQUEST # <br />,SROC86q5(0 <br />OWNER! OPERATOR <br />CHECK if <br />Daniel & Sarah Correa <br />BILLING ADDRESS <br />FAciury NAME <br />FIRED PIZZA 6rri' A ei) <br />( <br />,A 0 r <br />I <br />SITE ADDRESS 678 <br />Street Number <br />SUITE A <br />Direction <br />WHISTLER WAY <br />Street Name <br />STOCKTON <br />City <br />95209 <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 10247 <br />Street Number <br />PAULSELL DRIVE <br />Street Name <br />CITY STATE ZIP <br />STOCKTON CA 95209 <br />PHONE #1 EXT. <br />( 209 ) 242-4105 <br />AP N # <br />07014036 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />B OS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />DANIEL CORREA <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />FIRED PIZZA ( 209 ) <br />PHONE # <br />242-4105 <br />Ex-r. <br />HOME or MAILING ADDRESS <br />10247 PAULSELL DRIVE <br />FAX # <br />( ) <br />Crry <br />STOCKTON <br />STATE CA ZIP 95209 <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, ST ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Z7a-e-e-a Ce4A-49-a- DATE: 3///2"3 <br />PROPERTY/BUSINESS OWNER 21 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT 0 OWNER <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 environmenta <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />"•-E-i V0 <br />A.( „A) .i., t 2za rti-cri ( ,‘,e.-, alp- 'hk--,,... ltfAR <br />COMMENTS: 2 _--kot ihrAt., (2e kit,it a) <br />SA A, <br />0 3 20g <br />43 <br />1111L 7- /R°A/4/1 C°ON <br />ii) riq..N r <br />ACCEPTED BY: Ca yew ,e s 6 0 EMPLOYEE #: DATE: 1 , 1 <br />ASSIGNED TO: <br />afir.-04.,^e C 14,2 <br />EMPLOYEE #: DATE: ,......_, <br />Date Service Completed (if already completed): SERVICE CODE: C "I ;-7) PIE: /6,0) <br />Fee Amount: . g I • 2 " • - - - Amount Paic103a DO Payment Date )/I <br />Payment Payment Type <br />/.$14.---- <br />Invoice # Check # /go-J o. Received By: (A9 <br />ite assessment <br />e it is <br />A/ <br />EHD 48-02-025 SR FORM (Golden Rod). <br />REVISED 11/17/2003