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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 ( � Z � kool <br /> OWNER i OPERATOR CHECK If BILLING ADDRESS ❑ <br /> David Bains <br /> FACILITY NAME <br /> Piara Pizza <br /> SITE ADDRESS 8014 Lower Sacramento rd 5 .� �,4 Stokton 95210 <br /> Street Number Direction I Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 916 ) 730 -4896 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS EY <br /> Arturo Villavicencio <br /> BUSINESS NAME PHONE # ExT. <br /> Diaz Architectural Design 909 52M180 <br /> HOME or MAILING ADDRESS FAX # <br /> 6654 Ventura pl ( ) <br /> CITY Cucamonga STATE zip <br /> Rancho <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 : Arturo Villavicencio DATE : 05/ 15/2021 <br /> PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT l] Agent <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 : A <br /> COMMENTS : <br /> We are requesting a health permit for a take out pizzeria that is been vacant for a month ✓(/ V�� <br /> Np <br /> J �ct vu , � � p ) � : SBA/ do 9 ?1 <br /> J / l E4 Ty oO MECo NTY <br /> ACCEPTED BY : CLCVrvI {SG ( > EMPLOYEE #: DATE : 6 � . 2 <br /> '.� ( T M T <br /> ASSIGNED TO : t/1Wl . EMPLOYEE # : DATE([[�j� 12.,Date Service Completed ( if already completed ) : SERVICE CODE : � ` Z3 1 P 1 E : l <br /> loe <br /> Fee Amount: �5�b Amount Pai u &* 4 Payment Date �p <br /> Payment Type S � Invoice # Check # ZG Z52 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />