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rc rN0-9-cra ng-‘ic <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Food and beverage <br />FACILITY ID # <br />0024074 <br />SERVICE REQUEST # <br />S12-00S5-1*19 <br />OWNER! OPERATOR CHECK if <br />..,.Kays Creation <br />BILLING ADDRESS <br />FACILITY NAME <br />POP <br />SITE ADDRESS 563 <br />Street Number Direction <br />W Clover Rd <br />Street Name <br />Tracy <br />CO <br />95376 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) . 535 <br />Street Number <br />W. Cancion C1 <br />Street Name <br />CITY STATE ZIP <br />Mountain House Ca 95391 <br />PHONE #1 EXT. <br />i 510) 600-1240 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS Fax # <br />( / <br />Crry 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 <br />or activity will be billed to me or my business as identified on this form. <br />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: <br /> Karen DATE: 5/21/2021 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER CI 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 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 at the same time it is <br />provided to me or my representative. <br />Title <br />TYPE SERVICE REQUESTED: CAsNeN C sop) OF s 1/4 ..1,k)\--erdaA2Ary-,‘ cojc,......;\% fTh c <br />COMMENTS: <br /> <br />Recg, <br />Al 2 , <br />SAN 4 . Jo <br />ENy 4 QU/N HEAL T IROlvm C( t-t 0 rAn 5)) <br />ACCEPTED BY: 1....: N. n \r` \o \ i 42,2 EMPLOYEE #: DATE: S...-ZN <br />ASSIGNED TO: U\ n \no1/4 (es EMPLOYEE #: DATE: 5— 2.4 _ 2_t <br />Date Service Completed (if already completed): SERVICE CODE: oko PIE: k soo 2 <br />Fee Amount: ‘ S 2_— Amount Paid kS a .-- Payment Date <br />Payment Type c c Invoice # , Received By: 110_ Check # i z5-7 77070 <br />SC& EFID 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />.020541 01SC