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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Merchantile Tl QS SQWg2`��2 <br /> OWNER/OPERATOR <br /> WInCoFoods, LLP FAOOH i85 CHECK if BILLING ADDRESS El <br /> FAViyn�'oFFoods #10 m0y)- -il IDa IQ <br /> SITE ADDRESS hex Avenue Stockton 95210 <br /> 5110 Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE 41 EXT. APN# LAND USE APPLICATION# <br /> c ) <br /> 001ko—p3—D23 <br /> PHONE#2 EXc BOS DISTRICT LOCATION CODE <br /> 1 I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dawn Cardwell <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHGNE# Exr. <br /> Petersen Staggs Architects 208 345-1462 <br /> HOME or MAILING ADDRESS `AY108) 345-1547 <br /> 5200 W State Street <br /> CITY Boise STATE ID ZIP 83703 <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: July 9, 2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORtZEDAGENT[N Sr. Project Manager <br /> IfAPPL/CANT is not the BILLLVG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 REQUESTED: Tenant Improvement Plan Review A y FN <br /> COMMENTS: l I i <br /> Ve.O <br /> HF GT DOIyI 0 <br /> N Ep Ety �Ty <br /> ACCEPTED BY: v-rK erj GCS- EMPLOYEE#: _ —2,0 DA� a ` FNr <br /> ASSIGNED TO: YL/ I1 EMPLOYEE#: � DATE: <br /> Date Service Completed (if already completed): SERMCE CODE: P I E: <br /> Fee Amount: $456.00 Amount Paid 7- �U Payment Date 7 Z� <br /> Payment Type Vi':SA— Invoice# Check# Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />