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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Matt Millon <br />FACILITY ID # <br />BUSINESS NAME <br />Permit Advisors <br />REQUEST # <br />Mercantile, Retail <br />HOME or MAILING ADDRESS <br />t �6 <br />/© <br />8370 Wilshire Blvd. #330 <br />CSERVICE <br />Z <br />OWNER/ OPER �� <br />C <br />ENVHEALTH L TY <br />C <br />CHECK if BILLING ADDRESSO <br />r'iArre�tri <br />'Ltt F tUl� <br />orr� erel C:l I V t 1 <br />OEPA <br />ENTJ <br />ACCEPTED BY: <br />V I <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />c <br />FACILITY NAME <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />Bob's Discount Furniture <br />'ISERVICE <br />P / E: 0/ <br />Fee Amount: <br />Amount Paid <br />SITE ADDRESS <br />i o <br />F116 <br />Payment Type <br />Invoice # <br />Check # F3 <br />f8 Street Number <br />Direction <br />Trinity Pkwy <br />Street Name <br />Stockton Cit <br />9521 <br />i ode <br />HOME or MAILING ADDRESS (If Different from Site A dress) <br />mww� <br />L&rn'N <br />3i <br />LC)Street <br />umber <br />Street Name <br />CITY <br />$TATEZIP <br />f 0�� j <br />PHONE #'I <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />( ) (K&D -339�- (`128. <br />PHONE #2 <br />( ) <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property <br />Matt Millon <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Permit Advisors <br />PHONE# ExT, <br />585 530-7220 <br />HOME or MAILING ADDRESS <br />FAx# <br />8370 Wilshire Blvd. #330 <br />SAN'OAQUIN <br />( ) <br />C <br />ENVHEALTH L TY <br />CITY Beverly Hills <br />STATE CA ZIP 90211 <br />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: y� yrtAoAA <br />yL DATE: 8/13/21 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT VJ Agent <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titre <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 4,the same time it is <br />provided to me or my representative. JAytMFR►�- <br />TYPE OF SERVICE REQUESTED: Health Review E� V <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />E <br />COMMENTS: <br />AUG 16 <br />U U 2021 <br />SAN'OAQUIN <br />C <br />ENVHEALTH L TY <br />OEPA <br />ENTJ <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />T� ���•� <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />CODE:S2 <br />I <br />'ISERVICE <br />P / E: 0/ <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />SCPt OD I <br />F116 <br />Payment Type <br />Invoice # <br />Check # F3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />