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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SEASONAL RETAIL SPECIALTY FOOD STORE SR0w �31 <br /> OWNER/OPERATOR HICKORY FARMS, LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME HICKORY FARM#13718 <br /> SITE ADDRESS PACIFIC AVENUE STOCKTON 95207 <br /> 4950 Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) HAVEN AVENUE <br /> 2510 Street Number Street Name <br /> CITY (STATE Zip <br /> JOLIET <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (815 )462.0274 X1938 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> JOE NORCROSS CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> HICKORY FARM#13718 815 462.0274 X1938 <br /> HOME or MAILING ADDRESS FAx# <br /> 2510 HAVEN AVENUE ( ) <br /> CITY JOLIET STATE IL Zip 60433 <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER E9 OPERATOR/MANAGER ❑ 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 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTEMPERMIT TO OPERATE RETAIL MALL KIOSK/SPECIALTY FOOD STO ME <br /> COMMENTS: q i ' 7 ,wO r-+ —ho <br /> t�l veb <br /> blah lRq J2-1'K (2 Al�cOr firms o� SgNJ�N �3 ?019 <br /> It E/w,K NINCOVN <br /> D',�7Y X CI S-3 ��THCEPgRelq <br /> ACCEPTED BY: �CL�r�C S U EMPLOYEE#: DATE: C�` •( L —( <br /> ASSIGNED TO: fi% - t" -- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �: P 1 E: (C.,() 2 <br /> Fee Amount: l _ Amount PaisPayment Date <br /> 11-3 <br /> Payment Type Invoice# 32?> Z 32 Check# 8/371 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />