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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Take out pizzeria Sip <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> David Bains <br /> FACILITY NAME <br /> Piara Pizza <br /> SITEADDRESS 8014 Lower Sacramento rd A— Stokton 95210 <br /> Street Number Direction I 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 Exr. APN# LAND USE APPLICATION# <br /> (916 )730-4896 <br /> PHONE#2I Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Arturo Villavicencio CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Diaz Architectural Design 909 20-9180 <br /> HOME or MAILING ADDRESS FAX# <br /> 6654 Ventura pl ( ) <br /> CITY STATE ZIP <br /> Rancho Cucamonga <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: Arturo Villavicencio DATE: <br /> �I 05/15/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1GAgent <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 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: A <br /> COMMENTS: CE FiyT <br /> We are requesting a health permit for a take out pizzeria that is been vacant for a month ` ,VA O <br /> Neu ,vt (p) <br /> ✓�N�d:l4c, 1V'10 Liyo 9NTY <br /> ACCEPTED BY: C—�'[V/'" EMPLOYEE DATE: 6 I��/L/ r/1iJ ryT <br /> ASSIGNED TO: EMPLOYEE M DATE& Glr _2_ <br /> Date Service Completed (if already completed): SERVICE CODE: s Z f7 VI 1 P I E:: <br /> ie <br /> Fee Amount: Amount Pai �67, OD Payment Date "LZ/ <br /> Payment Type ,S� Invoice# Check# Z� ��7 Received By: <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/2003 O 1,!(A 1-2- <br />