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s' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 409\q99 <br /> RVICEE REQUEST# <br /> HOSSANA VENTURES S <br /> OWNER I OPERATOR <br /> TINUADEIADEBANJI AIKU CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2271 <br /> STE 116 Street Number Direction GRANT SItNe NameROAD TRACYCI 95 9Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) W. HUNTINGTON AVENUE <br /> 183 Street Number Street Name <br /> CITY STATE ZIP <br /> MOUNTAIN HOUSE CA 95391 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 032 ) 955-3417 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 633-5420 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex. <br /> HOME or MAILING ADDRESS FAx# <br /> ( 1 <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 /> 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: 04/14/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ® OTHER,AUTHORIZED AGENT <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available a at the same time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED:AFRICAN/CARIBBEAN GROCERY STORE C�: <br /> COMMENTS: SA IV OR � <br /> , <br /> MegCT � COE <br /> P MENTy <br /> ACCEPTED BY: 11 CC—re �.$ (�� EMPLOYEE#: DATE: -C -'1� <br /> L <br /> ASSIGNEDTO: , Xvx In EMPLOYEE#: DATE: ,oC—` , Q� <br /> Date Service Completed (if already completed): SERVICE CODE: I <br /> PIE: r �/ <br /> Fee Amount: jo — Amount Pai Ts0r D Payment Date <br /> Payment TypeInvoice# Check# f /tP � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ped, 1gloll1 5 <br />