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San Joaquin County Environmental Health Department <br />Owner / Operator Sajad Shakoor <br />Facility Name Falafel Corner <br />Site Address <br />Direction Street Name City <br />City State <br />Ext.APN #Land Use Application # <br />^'3 <br />Ext.BOS District <br />mtCONTRACTOR / SERVICE REQUESTOR <br />Requestor Muhammad Siddique Check if Billing Address <br />Business Name Muhammad Siddique <br />Home or Mailing Address 6060 Sunrise Vista Dr. 2400B <br />) <br />City State Zip 95610 <br />12.01.23APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Date:Employee #:Accepted By: <br />Date:Employee#:Assigned to: <br />Fee Amount: <br />173^8^-7^Invoice # <br />SR FORM (Golden Rod) <br />Phone#2 <br />() <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Ext. <br />^■2-0^ <br />SERVICE REQUEST# <br />Phone #1 <br />(916)620-4065 <br />2432 W |<ettleman Ln. Lodi, CA 95424 <br />Street Number <br />Type of Business or Property <br />Restaurant <br />2432 W k|ettlemar|i Ln. Lodi, CA 95424 <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />SERVICE REQUEST <br />FACILITY ID # <br />Citru^Heights <br />BILLIN<; 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 />Street Name <br />Zip <br />< i _______ <br />Date Service Completed (if already completed): <br />Fax# <br />J <br />CA <br />Service Code: <br />Payment Date <br />_____________ <br />Payment Type <br />^.(4 <br />Check if Billing Address lx] <br />Zip Code_____ <br />-------- part^Nt <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 />____________ Date:. <br />Property / Business Owner Operator / Manager D O i her Authorized Agent [HI <br />If APPLICANT is not the BILLING Party, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE. INFORM ATION: 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 environmcntal/sitc assessment <br />information to the San Joaquin County Environmental. Health Department as soon as it is available and at the same time it is <br />provided to me or my representative. <br />AmountPaid^^^^^ <br />Check # <br />p <br />127 iV t-V <br />* <br />Received By: tff/I