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(Z. 0 5 c)3 1 \ -I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Retail food market <br />FACILITY ID # <br />-EA 000 02-c-,-, <br />SERVICE REQUEST # <br />SV- 0 0 1Q2 C;\ <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS Olive Oil Pantry, LLC DBA The Islands Market <br />FACILITY NAME <br />The Islands Market <br />SITE ADDRESS <br />950 Street Number W Direction Manthey Rd Street Name Lathrop City <br />95330 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />P.O. Box 4033 Street Number Street Name <br />CITY STATE Zip <br />Manteca CA 95337 <br />PHONE #1 EXT. <br />( 209) 825-7500 <br />APN # <br />21003005 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(209) 328-3288 <br />EMAIL <br />caroline@theoliveoillady.corn <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />1:1 <br />Ty <br />REQUESTOR 0 \..\.i.t., 0 \ \ ,ckv\.\\(:_ss , \.._\.,c, ,sce,ik <br />---C\crC, ----5\ ck\c\,*0( if BILLING ADDRESS <br />VN.C4( \t-XN.8 <br />BUSINESS NAME _\--- _.1., 00(\ 6kc. ,\ cxx c..._Is P(HIE4c‘ --\061' <br />HOME or MAILING ADDRESS 2Q ,ce2 0 ,../.. LA0 ,,...,..3 FAX # <br />( ) <br />CITY \NI\ cv-\_\-fic STATE C.., p‘ ZIP CA. -5---6--\ EMAIL <br />C (XY 0 \\•( --\\(.\-C P\ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of s , <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 />J <br /> <br />DATE: 02/06/2024 <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El Business Owner <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Ti: Fe <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 provided toisie Or my <br />representative. <br />TYPE OF SERVICE REQUESTED: Change of Ownership Consultation <br />COMMENTS: <br />0 5 <br />Pkl? <br />202, %AI J0,4 n <br />W ON ty "-N1,/if y <br />I \ 14 4 .,C 0 0 N <br />0 -1 : , , , -iRr4,7 .--Al <br />ACCEPTED BY: L; EMPLOYEE #: DATE: 2_ . kc, • 2_ Li <br />ASSIGNED TO: ‘ ‘ EN, \e'N.C;\ ( e''.---.., EMPLOYEE #: DATE: 2_.o . 2 Lf <br />Date Service Completed (if already completed): SERVICE CODE: 0 kz, I PIE: 1 to oz <br />Fee Amount: $162.00 Amount Paid <br />1 ko 2 — Payment Date 2._. ko <br />Payment Type C c Invoice # Check # i 76. 2 ,5-- I Received By: <br />Co r\--e 2 I <br />EHD 48-02-025 <br />03/22123 <br />SR FORM (Golden Rod)