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eczosq,1-2so <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />GROCERY STORE <br />FACILITY ID # <br />c-A01125H-B1 <br />SERVICE REQUEST # <br />SR0005-4(e73\ <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS .4. MOHAMED RAFIQ KASSIM AL FAHD <br />FACILITY NAME PRIMO DISCOUNT MARKET & MORE <br />147 <br />Street Number Direction <br />SITE ADDRESS 95202 N AURORA ST <br />Street Name <br />STOCKTON <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/C\ 0 1 E -,-t Street Number Street Name <br />CITY STATE ZIP <br />0 aka )2 J c fA 'fvo/c / <br />PHONE #1 EXT. <br />(5)o ) Ci7q -07 3 7 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR MOHAMED RAFIQ KASSIM AL FAHD CHECK if BILLING ADDRESS Ord' <br />BUSINESS NAME PRIMO DISCOUNT MARKET & MORE PHONE # <br />(415) 319-4050 <br />EXT. <br />HOME or MAILING ADDRESS <br />147 N AURORA ST <br />Fax # <br />( ) <br />CITY STOCKTON NATE ZIP 95202 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: MOHAMED RAFIQ KASSIM AL FAHD DATE: <br /> <br />/crAL z <br /> <br />PROPERTY! BUSINESS OWNER Et OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY proof of authorization to sign is required <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 providedpAfe Or my <br />M - w <br />TYPE OF SERVICE REQUESTED: K e Lk-) <br />COMMENTS: * / 024 <br />St' J <br />2 <br />OA Qui <br />ki,...t NV <br />" ti <br />/ROA ,AliV couN-, <br />''`-'11-ro i, tvrAL ' - ARTA,zNT <br />ACCEPTED BY: <br />-riA es L-- -0 <br />EMPLOYEE #: DATE: (.._/ <br />ASSIGNED TO: t t.,--')—(;) EMPLOYEE #: DATE: i ___/ <br />Date Service Completed (if already completed): SERVICE CODE: - 1 <br />c PIE: ()2 ,- <br />Fee Amount: i t2 - Amount Paid /6.2. (,.7D Payment Date ,/J7/2 <br />Payment Type —1- Invoice # Check # j 7 5 —0 23 - : 0 Received By:en <br />Title <br />representative. <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod)