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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST l#" <br /> RESTUARANT -IF A 0c ) I Lj 31 5 90 'j� T 3 <br /> OWNER/OPERATOR <br /> ASAD KABIR SHAH CHECK If BILLING ADDRESS <br /> FACILITY NAME KABOBMTES Pa, �SO$ M Tri <br /> SITEADDRESS 2521 N TRACY BLVD TRACY CA <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E77 APN# LAND USE APPLICATION# <br /> ( 510 ) 8809223 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ASAD KABIR SHAH CHECK if BILLING ADDRESS© <br /> BUSINESS NAME PHONE# E'T. <br /> KABOBMATES <br /> HOME or MAILING ADDRESS FAX# <br /> 21330 S CORRAL HOLLOW RD ( ) <br /> CITY TRACY STATE CA ZIP 95376 <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 /> 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: *. 1("'Q It-- DATE: 03/29/2021 <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> fAPPLICANT is not the B/LLWG PARTY proof of authorization 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 environmenta1�l/s�ite,ya,�ssre�ssamaeynct <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t'f'R7'7�a 1' <br /> provided to me or my representative. REECEIV <br /> TYPE OF SERVICE REQUESTED: CHANGE OF OWNERSHIP HEALTH INSPECTION <br /> COMMENTS: MAR 2 9 2M <br /> SAN JOAQUIN COUN FY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L EMPLOYEEM DATE: <br /> ASSIGNED TO: L'\ ^\-\p\r.e EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: pIo P I E: <br /> Fee Amount: \ S 2 — Amount Paid \ Payment Date <br /> Payment Type L C- Invoice# eck# ` 2 2 8 / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />