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Owner / Operator <br />Raj Mohan <br />Facility Name Cousins Maine Lobster <br />Site Address <br />Direction <br />City <br />Ext.APN # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Raj Mohan <br />Business Name Cousins Maine Lobster <br />Home or Mailing Address 6841 Village Pkwy ) <br />City State Zip 94568Dublin <br />1/30/2024APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />4-5-24Vidal Pedraza 6213 Date:Employee #:Accepted By: <br />9838Francisco Ruiz Date: 4-5-24Employee#:Assigned to: <br />Service Code:61 P/E:Date Service Completed (if already completed): <br />162Fee Amount: <br />Payment Type Invoice # <br />SR FORM (Golden Rod) <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 <br />or activity will be billed to me or my business as identified on this form. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />mff consultation <br />He will bring the mff on 4-8-24 at 10:00 <br />Type of Business or Property <br />MFF <br />_____Dublin <br />Phone #1 <br />( 916)270-2674 <br />SERVICE REQUEST# <br />ROT <br />Phone#2 <br />() <br />Richards Blvd <br />___________Street Name <br />6841 <br />Street Number <br />95811 <br />Zip Code <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 />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />1100_________________Street Number <br />Home or Mailing Address (If Different from Site Address) <br />Sacramento <br />________________City________ <br />Village Pkwy <br />_______________Street Name <br />State Zip <br />CA___________94568 <br />Land Use Application # <br />Payment Date <br />Check if Billing Address <br />Amount PaidC^ <br />Check# <br />Phone# <br />J____L <br />Fax# <br />( <br />CA <br />1603 <br />Received By: /j/' <br />Check if Billing Address UJ <br />Exr k- <br />Date: <br />Property / Business OwnerHJ Operator / Manager Other Authorized Agent O <br />If Applicant is not the Billing Part}', 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the San Joaquin COUN TY Environmental HEALTH Department as soon as it is available and at the same time it is <br />provided to me or my representative. <br /> T^Nr