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93726 <br />Zip CodeDirection <br />Street Number <br />City Fresno <br />Ext.Land Use Application #APN# <br />293-9743 <br />Ext.Location CodeBOS District <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />TBD Muhammad Bablu Molla <br />Ext.Business Name 293-9743 <br />Home or Mailing Address 4660 N First Street <br />Zip 93726FresnoStateCity <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Date:Employee #: <br />Date: <br />Amount PaidFee Amount: <br />Invoice # <br />SR FORM (Golden Rod) <br />Owner / Operator <br />Muhammad Bablu Molla <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />State <br />CA <br />Type of Business or Property <br />grab and go bakery, no seats, no alcohDl <br />Phone #1 <br />( 559 ) <br />Stockton <br />City <br />SERVICE REQUEST# <br />Phone #2 <br />(____) <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />___________________Street Number <br />Home or Mailing Address (if Different from site Address) <br />4660 <br />Trinity Pkwy <br />Street Name <br />Check if Billing Address B <br />Check if Billing Address Q <br />Employee#: <br />Service Code: <br />Payment Date <br />P,E: <br />Received By: <br />N First Street <br />____________Street Name______ <br />Zip <br />93726 <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 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. J / <br />FACILITYWe^ZerS Pretzels <br />Site Address <br />10355 <br />Check# <br />AccepteoBy: <br />Assigned to: /j <br />Date Service Completed (if already completed): <br />Payment Type <br />Date: <br />Property / Business Owner Operator / Manager 0 Other Authorized Agent <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 al 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 time it is <br />provided to me or my representative^___________________________________________T <br />Otf W), <br />Rr^llT <br />Fax# <br />J___1 <br />CA