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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />MARKET AND DELI <br />FACILITY ID # <br />(A J1/4,-'''N q -/& <br />SERVICE REQUEST # <br />OWNER! OPERATOR CHECK if BILLING ADDRESS <br />OSAAMA JUBARY <br />FACILITY NAME HABIBI'S INTERNATIONAL MARKET <br />SITE ADDRESS 137 <br />Street Number Direction <br />N MAIN ST <br />Street Name <br />MANTECA <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 Exr. <br />(209 ) 239990 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />SERVICE RE UESTOR <br />REQUESTOR OSAAMA JUBARY <br />_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME HABIBI'S INTERNATIONAL MARKET PHONE # EXT. <br />09 239990 <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />Crry STATE ZIP EMAIL <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 />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: <br /> <br />DATE: 01/19/2024 <br /> <br />PROPERTY / BUSINESS OWNER 12 OPERATOR I MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 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 providel3o me or my <br />AY <br />- <br />— . <br />TYPE OF SERVICE REQUESTED: (4) fri-,AS c . .,..,..,e ,z6, 0 I /-1-1 Est j <br />COMMENTS: JAN 2 g <br />84 N JoA 2024 <br />'Ai 4 Quhv <br />r-1 D E P4 L:ION,774 ( r ', / 4,7 •Air <br />ACCEPTED BY: C--1 <br /> <br />EMPLOYEE #: ...-3s DATE: I 2 , <br />ASSIGNED TO: 6 e h oil it) fit ' <br />EMPLOYEE #: Li? •.. ?-- ,o f,.3 DATE: <br />Date Service Completed (if already co pleted): SERVICE CODE: , r ( . / P/ : n 2 <br />Fee Amount: ( 6 2— Amount Pa ).on Payment Date 1/zi,2_1 / <br />Receiv d By: ,ze_ <br />Payment Type ; Invoice # Check # ) 7---2_06 L <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br />PR OS235'15