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SAN JOAQUIN COUNTY ENVIRONN1ENTAI, IlEALTII DEPARTMENT <br />SERVICE REQUEST FA0 a a 33 <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # i <br />PRO 5o,Sr9- 0. <br />SERVICE <br />SiZa400t <br />CHECK if <br />REQUEST # <br />4_4 <br />BILLING ADDRESS OWNER / OPERATOR <br />Pacific Ave Bowl <br />FAciure NAME THE BOWL café <br />SITE ADDRESS 5939 <br />Street Number Direction <br />Pacific Avenue <br />Street Name <br />Stockton <br />City <br />95219 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE 01 Err. <br />( ) 209-636-2288 <br />APN # LAND USE APPLICATION # <br />PHONE #2 E. <br />209-608-4189 ( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME Or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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 />I also certify that I have prepared this applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards .i i nd FEDERAL laws. <br />411r0 <br />RATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saPAiloe it is <br />idecl tome or my representative. r M <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNERI21 <br />DATE: <br /> 5/7/2024 <br />TYPE OF SERVICE REQUESTED: C,0-11.5‘a,,171-7 oy-) <br />COMMENTS: oLt)rie,izsi,,,p ( , . <br />DATE: <br />1-1 -1\11/1R‘QUIA1 <br />DATE: ._57722, <br />kly o <br />84N JO., <br />C ALT H 00A/4/76/v?U <br />&-rz,„4 f, 7,11.141 <br />Il <br />5/ 7/1I q <br />ACCEPTED BY: L tAtcy,____---- EMPLOYEE #: 0 <br />ASSIGNED TO: ,t(A EMPLOYEE #: 6)8, <br />Date Service Completed (it already completed): SERVICE CODE: 1 <br />94 <br />.2 7 PIE: /0-,7_____ <br />Fee Amount: 71/ (1). (72-- Amount Paid( Payment Date <br />Received <br />,5/7/24 <br />Payment Type CA(10/ i Invoice # Check # ig/ OS,56—Dei By: <br />SR FORM (Golden RG(1) END 48-02-025 <br />REVISED 11 /17/2003 14-ga5S