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."pelt ?0 /`f rr? �rn��,,u te�L l/dU <br /> SAN JOAQLA..000NTY ENVIRONMENTAL HEALTH 6—PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RESTAURANT FULL SERVICE /T�OOC����dCl <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> NICOLAS & JUAN SANCHEZ <br /> FACILITY NAME <br /> RA I C.1 IISINE ) <br /> SITE ADDRESS 95376 <br /> AIA Street Number Direction (reel Name TRAGY Zi Cade <br /> F:T <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1460 JONES LN Street Number Wet Neme <br /> CITY STATE CA ZIP <br /> TRACY <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( 20� 666-1020 2664 SQ FT <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 510 384-1727 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR NICOLAS SANCHEZ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> oNtE l�1gII�GA Rig 2 9 666-1020 <br /> H ?'ed JUNEgDLNS FAx ) <br /> CITY TRACY STATE CA ZIP 95377 <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 <br /> 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. /L <br /> APPLICANT'S SIGNATURE: NICOL>4� SANCItEZ DATE: /gZyLtl2-lll5`�( <br /> PROPERTY I BUSINESS OWNER 9 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 2jyR/ E RLll/e <br /> If APPLICANT is not the BILLING PARTY Proof Of authorization to S%yn IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It is available and at the same time It is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �y <br /> R21 <br /> NFSQV�N p/�rME OU vry <br /> ACCEPTED V: l� EMPLOYEE#: T��� DATE: ��E T <br /> 'ooASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: PIE: %Qct <br /> Fee Amount: �'�� Amount Paid ¢' / Payment Date 41,2-0116- <br /> Payment <br /> I,2-D/16- <br /> Payment Type , Invoice# LpL - <br /> i uReceived By: , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />