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REQUESTOR <br />T.B.D <br />CHECK if BILLING ADDRESS <br /> <br />BUSINESS NAME PHONE # <br /> EXT. <br /> <br />HOME or MAILING ADDRESS FAX # <br />) <br /> <br />CITY <br /> <br />STATE ZIP <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />RESTAURANT <br />FACILITY ID # <br />1 -1 41 <br />SERVICE REQUEST # csier., , ,-• f ,_) 27 I /..ni <br />OWNER / OPERATOR ASHOK VERMA CHECK if BILLING gA ADDRESS <br />FACILITY NAME STAR INDIA SWEETS & CATERING <br />SITE ADDRESS 209 <br />Street Number <br />E. <br />Direction <br />LOUISE AVE <br />Street Name <br />LATHROP <br />City <br />95336 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 ExT. <br />( 209 ) 681-5171 <br />APN # <br />196-27-30 <br />I LAND USE APPLICATION # <br />PHONE #2 E. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized nt of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated 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 accordan wit .11 SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> Ve..rvo.d. <br />DATE: <br />01-30-23 <br />PROPERTY / BUSINESS OWNERS OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 />provided to me or my representative. <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tIPArp. time it is <br />.1v 7 <br />TYPE OF SERVICE REQUESTED: <br />1 l'A <br />t2,2 if,...„-eke,f2,60 (-0--tre,( —-,--(1, Ay (..-E.,;- <br />f) COMMENTS: j4 /V 3 <br />So4N 4 0 43 <br />$•,‘„ 04 Q u <br />6t12:7-041//N C <br />Al 00,41F44)41/7), xli tifilL. <br />eivr <br />ACCEPTED BY: Ca (Irv( .es c.. o EMPLOYEE #: DATE: I ,,,_ 30 ,_,2_3 <br />ASSIGNED TO: \..2‘A kelex, foe C EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 6'2_5 P/E: 1600 ( <br />Fee Amount:A Lm Amount Paid 1.1L6F, ry) Payment Date V36/23 <br />Payment Type iii,....._ Invoice # Check # J7 L5S-0 / Received By: di) <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003