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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RESTUARANT t A oo (y3lS l� 'Y�T3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ASAD KABIR SHAH <br /> FACILITY NAME KABOBMTES tq �SOg tA f= -T4ES <br /> SITE ADDRESS 2521 N TRACY BLVD TRACY CA <br /> Street Number Direction Street Name city Zip Cod. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EaT. APN# LAND USE APPLICATION# <br /> (510 ) 8809223 <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ASHD KABIR SHAH CHECK If BILLING ADDRESS© <br /> BUSINESS NAME PHONE# ExT. <br /> KABOBMATES <br /> HOME Or MAILING ADDRESS FAX# <br /> 21330 S CORRAL HOLLOW RD ( ) <br /> CITY TRACY STATE CA ZIP 95376 <br /> BILLING ACKNOWLEDGEMENT: 1, 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: *µ' 7*-d/�— DATE. 03/29/2021 <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of dte property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenta <br /> I�l/s�iteVa,�ssre�ss�m;re-nr�t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t`rI`C'1'7�E 1' <br /> provided to me or my representative. RECEINIM <br /> TYPE OF SERVICE REQUESTED: CHANGE OF OWNERSHIP HEALTH INSPECTION <br /> COMMENTS: MAR 2 9 20V <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME T <br /> ACCEPTED BY: r0r\o, / EMPLOYEEM DATE: <br /> ASSIGNED TO: (-\ v \ EMPLOYEE DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Ob ) P 1 E: /0b02. <br /> Fee Amount: \ S 2 Amount Paid Payment Date <br /> Payment Type LL Invoice# Qirekk# Z 2 8 / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED II/17/2003 U �bn ei <br /> l �5 <br /> K 5 <br />