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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID I SERVICE REQUEST I <br /> Catering walk up diner <br /> OWNER/OPERATOR <br /> Sabrina inocencio CHECK II BILLING ADDRESS <br /> FAcAnrNaue BreezieS Homecookn <br /> SITE ADDRESS South Chrisman road <br /> 3$2 fret Numeer <br /> NOME or MAILING ADDRESS (N Different from Site Address) <br /> tr .I N�mew <br /> CITY STATE LP <br /> PHM I7 m• APN a LAND USE APPLICATION e <br /> (slo) HiQ �- 5 3q3 <br /> PHONE 92 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR Sabrina inocencio CHECK U@IL{ma ADDRFs <br /> BUSINEss NAME PHONE I Ext <br /> Breezieshome cookn <br /> HOME Of MAILING ADDRESS 25002 pleasant way FAX <br /> CITY Hayward STATE Ca ZIP 95376 - <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andhrc project specific ENVIRONMENTAL HEALni DEP1RTmENT 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(:odes,Slandarr(r,STATE and FEDERAL laws. <br /> 9/15/2022 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTI/BUSLNESSOWNE.R® OPERATOR/MANAGER I] oiHERAUTHORI7a:DAGENTC <br /> IJAPPLIC NT is not the fi14LL_(,LPJAn.proof of aathoritation 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 erivironincrital/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HF yLTN DEPARTMLNT as Soon US it is available and at the same time It is <br /> provided to me or my representative. <br /> TYPE of SERVICE REQUESTED: PAYMENT <br /> CDMRENrs: RECEIVED <br /> SEP 15 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: r �� EMPLOYEE I: DATE: <br /> ASSIGNED TO: � (�� EMPLOYEE S: DATE: <br /> Dab Service Completed (N already completed): SERVICE CODE: Ub 1 PIE: <br /> Fee Amount: \ S b Amount Paid `S b Payment Date S��Z <br /> Payment Type Invoice I Chaok 0 Received By: <br /> REVEHD SED 11/1 V#' I Q b Q t 5 ORM(Golden Rod) 6 <br /> REVISED Elft 7!2003 1 l�1 <br />