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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> Retail —J0 <br /> OWNER I OPERATOR <br /> Osi Techs Inc CHECK if BILLING ADDRESS <br /> FACILITY NAME Wayback Burgers <br /> SITE ADDRESS 3218W Grant Line Rd Tracy 95304 <br /> street Number Direction street Name city zip Cede <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2140 Street Number Pralta ave #209 Street Name <br /> CITY STATE ZIP <br /> Fremont Ca 94536-3960 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 834-8647 `F <br /> PHONE 92 EXT. BOS DISTRICT LOCATION DE <br /> ( 51C) 818-0092cf0'� 0 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> same as above CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 /> 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 Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: jawadqureshi DATE: 08/16/2018 <br /> PROPERTY I BUSINESS OWNER® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ President <br /> If APPLICANT is riot the BILLING PARTY,proof Of authorization t0 Sign Is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 l0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: CC-( iv PAYMENT <br /> I <br /> COMMENTS: RECEIVE <br /> AUG 17 2018 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> ACCEPTED BY: (-c EMPLOYEE M S (^ DATE: L' PARTMEN ' <br /> ASSIGNED TO: L \ \ \ : _= �- EMPLOYEE#. L� �� � DATE. S <br /> Date Service Completed (if already completed): SERVICE CODE v 2 PIE: <br /> Fee Amount: 0 5 Amount Paid ,S 2 Payment Date <br /> PaymentType � Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br />