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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Wine Bar <br />FACILITY ID if <br />3 PIS 00 -L LI 2 I <br />SERVICE <br />sko0639-cos <br />CHECK if <br />REQUEST # <br />BILLING ADDRESS conEB(ssp,woR <br />FACILITY NAME <br />The Press Wine Bar <br />SITE ADDRESS <br />165 w <br />Street Number Direction <br />10th <br />Street Name <br />Tracy <br />City <br />95376 <br />Zip Code <br />HOME OE MAILING ADDRESS (If Different from Site Address) <br />793 Street Number <br />S Tracy Blvd, S ite 117 <br />Street Name <br />Cox STATE ZIP <br />Tracy Ca 95376 <br />PHONE #1 Err. <br />( 209 ) 879-9639 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( 209 ) 834-6835 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />Tammy Jones <br />REQUESTOR ta CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Vine Divas, Inc <br />PHONE # <br />( 209 ) 879-9639 <br />En <br />HOME or MAILING ADDRESS <br />793 S. Tracy Blvd, Suite 117 <br />FAX # <br />I I <br />Cm{racy <br />STATE Ca <br />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: T,,,, DATE: 5/25/2021 <br /> <br />PROPERTY / BUSINESS OWNEREI OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT 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 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 />TYPE OF SERVICE REQUESTED: orc,...„/NQ Lib 0,....) r--12_"-. PA YME <br />- COMMENTS: <br /> RECE NT 1VED <br />MAY 25 2021 <br />SAN,ADA „ <br />HE ENV/R6tV,„/N COuN ry ALTH DefreNTAL APTm <br />ACCEPTED BY: Ls nv\o„.(-672._ EMPLOYEE #: DATE: S r <br />ASSIGNED TO: UN r\ \r\o\ I f 5 i EMPLOYEE #: DATE: -,..S. - Z S - a i <br />Date Service Completed (if already completed): SERVICE CODE: 0 co I PIE: kko02 <br />Fee Amount: \ s 2., _ Amount Paid 6Q.DO Payment Date 5/ 2.1 I <br />Payment Type c c Invoice # Check # 17_5 -3 71071 Receiv d By: <br />poost122-ia SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003