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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Bakery <br />FACILITY ID # <br />t- PI 00 2 2 SS <br />SERVICE REQUEST # <br />17•11767CIR <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />Asad Awawdeh <br />FACILITY NAME <br />Smallcakes <br />SITE ADDRESS 15040 <br />Street Number Direction <br />S Harlan rd <br />Street Name <br />Lathrop <br />City <br />95330 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />( 2c9 ) k0.±0 - S <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Exr. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP EMAIL <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 or activity <br />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: Asad Awawdeh DATE: 12/07/2023 <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT iS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propertM <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assmarpie <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time V <br />representative. <br />VAII al \dr-M.4%1111 %.0%./VIM I I <br />ENVIRONMENTAL TYPE OF SERVICE REQUESTED: (:),,..y.3c....Q.,"\ C. \-\ 0.„4-\,,..) _Q____ <br />HEALTH DEPARTMENT <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: L. <br />: \ Nr\VNO\ ( -E, _S EMPLOYEE #: DATE: \ 2 _ ‘ \ -a 2, <br />Date Service Completed (if already completed): SERVICE CODE: i,,co 1 P/ : \\43 ,zyz <br />Fee Amount: \ \z:) 2 _ Amount Paid .2 _ - Payment Date 2..., 2,4) 2- 'z.. <br />Recei ed By:,).?/' Payment Type V IC? 19 Invoice # Check # <br />PA ZENT <br />kepove site <br />rt ipf0A-14.4on to the <br />oLideltiLle or my <br />)2W SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23