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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ,,// SERVICE REQUEST# <br /> Restaurant/Wine Bar � 000/-5 7-,3 69(n8-:t NS <br /> OWNER/OPERATOR <br /> Wine Wizards LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> VVine Wizards <br /> SITE ADDRESS 95207 <br /> 2222 FStockton <br /> Street Number Direction Grand Canal Blvd.,street Name Suite 3 City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1919 Grand Canal Blvd.,Suite Al <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95207 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 957-7711 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> (209 ) 209-242-9971 jerry@butterfieldcpas.com <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Hanley CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Hanley Construction,Inc (209 ) 209-471-8100 <br /> HOME or MAILING ADDRESS FAX# <br /> PO BOX 808 ( ) <br /> CITY STATE ZIP 95201 EMAIL <br /> Stockton CA lim@hanleyco.com <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 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: e� DATE: September , 2023 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR I MANAGER ❑ 61 OTHER AUTHORIZED AGENT ❑ Manageing Member <br /> If APPLICANT Is not the BILLING PARTY proof ofauthorization 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 information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It IS provided t0 me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED:COnsulatlon Inspection RECEIVED <br /> COMMENTS: SEP 0 6 2023 <br /> 6AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: a EMPLOYEE#: DATE: <br /> ASSIGNED TO: / vv EMPLOYEE#: DATE: <br /> Date Service Complet (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: / (f Amount Paid / a Payment Date 2 <br /> Payment Type7 6 Invoice# Check# Receive B <br /> EHD 48-02-025 bg 3 oSR FORM(Golden Rod) <br /> 03/22/23 <br /> �l� X23 <br />