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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE RECILIESI # <br />QUICK SERVICE RESTAURANT 11 1 S(Z l i 5 <br />OWNER/ OPERATOR <br />SURAINDER SINGH <br />CHECK If <br />SITE ADDRESS WEST I MARKET STREET STOCKTON F. 12 Street Number Direction Street Name Cit LC. <br />HOME or MAILING ADDRESS (If Different from Site Address) (Z <br />23 M�^ 7 (GC'[- t F Street Number Street Name <br />CITY �S7An I L( - -3 <br />S /VI• ` O <br />PHONE#1 En. APN# LAND USE APPLICATION# <br />(925)719-2883 137-300-180 <br />PHONER EM• BOS DISTRICT LOCATION ODE <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR ji p � j <br />I t1 lam. '� l CHECK If BILLING EES L1 <br />BUSINESS NAME.� I�ehG Des/, PHONE# 97 Er <br />HOME Or MAILING ADDRESS W 7q LA �{ CS+ y P # )S_I ., JD {,G <br />CITY % _- I. l,-- c J X STATE i- it l-CLP4V1, r �— <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ager of sa pl <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with is proje <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared thisa liCation and that the work to be performed will be done in accordance with all S JDAQU <br />COUNTY Ordinance Codes, Standards, S Te and FEDE AL laws. <br />APPLICANT'S SIGNATURE: \t\ DATE: <br />PROPERTY/ BUSINESS OWNER® OPERATOR/MANAG OTHER AUTHORIZED AGENT❑ <br />I,ffAPPLICdNTisnotthe BILLINGPARTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property to ated at di <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site ss!ssme <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availableaDd at the s Eme It <br />provided to me or my representative. ' be a, <br />TYPE OF SERVICE REQUESTED: {'u <br />COMMENTS: ek {L'E /CJY1(C- <br />5 <br />mt�cl; VkJ6 <br />BgMCTV <br />"Pv <br />? <br />oa� <br />HFCNME <br />ACCEPTED BY: V, f ✓� S LL. <br />EMPLOYEE #: <br />DATE'FYNAL, <br />ASSIGNED TO: p��, e N -.� <br />EMPLOYEE #: <br />DATE: Z _� <br />Date Service Completed (If already completed): <br />SERVICE CODE: CZ?) <br />PIE: <br />Fee Amount: <br />Amount Pal <br />L1L 7 <br />egn <br />Payment Date ! <br />Payment Type <br />Invoice # <br />Check # 1 3S <br />Re ce ve By: <br />EHD 48-02-025 SR FORM ( olden R <br />REVISED 11/17/2003 <br />