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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Samuel Ogden <br />REQUEST # <br />Permit to Operate - 1626 Restaurant/Bar 101 + Seat <br />Z(� <br />PHONE # EaT' <br />/SERVICE <br />sa Wgi S ips . . <br />OWNER / OPERATOR <br />' <br />CHECK If BILLING ADDRESS� <br />SNH CAL Tenant LLC <br />- <br />FACILITY NAME <br />877 E. March Ln. <br />Rio Las Palmas <br />( ) <br />SITE ADDRESS <br />STATE CA ZIP 95207 <br />877 - <br />I <br />March Ln. <br />Stockton <br />95207 <br />Street Number <br />Direction <br />Street Name <br />cItx <br />zip Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />ATTN: Lansing 400 Street Number <br />Centre SL Street Name <br />CITY <br />STATE zip <br />Newton <br />MA 02458 <br />PHONE #1 EaT' <br />APN 11LAND <br />USE APPLICATION # <br />( 209 ) 401-3533 <br />LI o� <br />PHONE#2 Exr, <br />BOS DISTRICJ.�D�� <br />b <br />LOCATIQr\�ODE <br />lVJ <br />( 617 ) 796 8387 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Samuel Ogden <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EaT' <br />Rio Las Palmas <br />209 401-3533 <br />HOME or MAILING ADDRESS <br />FAx # <br />877 E. March Ln. <br />( ) <br />CITY Stockton <br />STATE CA ZIP 95207 <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 />1 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, ST'AK[ agi zDERAL laws. , I <br />APPLICANT'S SIGNATURE: /(G ykL/!'(/! J DATE: \ZI20I�q <br />L/ Jennifer Francis, Preaident & COO <br />I'ROI•ERl'Y/I)tf51SEs5 r)\YFEIi� DI'ERA'1'OR/ M:\S:\GER❑ D'I'ItER AL"1'IIORIZEDACENI'❑ <br />IfAPPLICANT 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 environmed/` `lye assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available andt9a4f, - is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:rChange of OJmership (effective 11112020) r% DPr <br />COMMENTS: ,per„ p19 <br />NCoUlf <br />�C� �fP f leAI <br />MENT <br />ACCEPTED BY: ce-i,-ir" G -S EMPLOYEE #: DATE: <br />ASSIGNED TO: Fu h'" V EMPLOYEE #: DATE: t'i.- 2 6 —/ i <br />Date Service Completed (if already completed): SERVICE CODE: m (p / P I E: ((00 2 - <br />Fee <br />Fee Amount: .�di2 im) Amount Pai /,5;? ov 77Payment Date N7 <br />Payment Type GL Invoice # Check # S� CJ Recei ed By: <br />EHD 48-02025 SR FORM (Golden Rod) <br />REVISED 11/171200:1 <br />