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?Ros1 /4-Igq, 061 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />3 UQ) S -I G 3? <br />OWNER / OPERATOR Ahmed Mused CHECK if BILLING ADDRESS <br />FACILITY NAME Saba live Poultry 4 <br />SITE ADDRESS 1320 <br />Street Number <br />S <br />Direction <br />Aurora ST <br />Street Name <br />Stockton <br />City <br />95206 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 2037 <br />Street Number <br />Marineview Dr <br />Street Name <br />CITY San Leandro STATE CA zip 94577 <br />PHONE #1 EXT. <br />209 ) 242 2998 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( 510 ) 422 2224 <br />EMAIL Sabapoultry4@gmail.com BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REduEsToR Hameza Musid CHECK if BILLING ADDRESS <br />BUSINESS NAME Saba Live Poultry 4 Err. PHONE # 422 2224 (510) <br />HOME or MAILING ADDRESS 1320 S Aurora St Fax # <br />( ) <br />crry Stockton STATE CA zip 95206 EMAIL sabapoultry4@gmail.conr <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: am Y.1./, DATE, 01/19/2024 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER Er 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 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 proplAVo me Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: CO 14 St..4 L:r Al. I C N <br />I ‘CCE.47V I <br />COMMENTS: JAN 1 n <br />'7 2024 <br />HE...QNVIR 65 - N Cou zALTH DENpME-N 7-4 ,Nry <br />AR 7-mg-NT <br />ACCEPTED BY: iyk 4 p,„.0 EMPLOYEE #: 93 28 DATE: <br />0 1 / I 9 /26 2.1+ <br />ASSIGNED TO: .."1 IA (2, 0 EMPLOYEE #: 9 g zg• DATE:0 I/I 43/ 243 2.4, <br />Date Service Completed (if already completed): SERVICE CODE: 04 I PIE: i(0 0 .2_ <br />Fee Amount: it 1 Co 2. . 00 Amount Paid #16,,,2 . OD Payment Date yr://)27L <br />- ----- Payment Type CkeAtt Invoice # Check # 17 s O ?4. 5 ,6-- Received By: (549 <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23