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""J- "o-� C� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> new retail food facility in an existing building Sec <br /> OWNER/OPERATOR <br /> Linda Osmundsen CHECK if BILLING ADDRESS® <br /> FAcILm NAME <br /> Ghirardelli Chocolate Com an <br /> SITE ADDRESS Promontory Parkway Tracy 95377 <br /> 1015 Sreet Number Dlree ton SVaet Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1111 139th Ave <br /> Street Number Sheet Name <br /> CITY San Leandro TA 94578 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> 1 510)385-6221 209-080-390-000 <br /> PHONE#2 fir- BOS DISTRICT LOCATION CODE <br /> I ) 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ian Tallon CHECK if BILLING AODRESSO <br /> BUSINESS NAME Northern Sun Associates, Inc PHONE# Em <br /> I It 650)871-1962 <br /> HOME or MAILING ADDRESS FAX <br /> 200 S Spruce Ave#9 1 ( ) <br /> CITY South San Francisco STATE CA <br /> LP 94080 <br /> BILLING ACKNOWLEDGEMENT: L 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 applicatio and t at the� ork to a performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a d FED'.RAL la-k. <br /> APPLICANT'S SIGNATURE: DATE: March 16.2021 <br /> PaoPERTY/BUSINESSOwNERO OPERAT /MANAGE TBE AUTHORIZED AGENTQ�hief Financial Offirzr <br /> IfAFpmcANr is not the BILLNG ARTY,proof of authorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFO TION: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 environmeAtal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and time it is <br /> provided to me or my representative. R rY. <br /> TYPE OF SERVICE REQUESTED: P `a(� ��—�� D <br /> AJA <br /> COMMENTS: <br /> SAN.ro 20ZI <br /> ENVY,AQU/N C <br /> NFq�rHD PAIolvmEN7AJ. <br /> rMe <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� o.fe EMPLOYEE#: DATE: <br /> Date Service Completed (ir already completed): SERVICE CODE: PIE-1UoI <br /> Fee Amount: ` 1 Sb— Amount Paid S b -- Payment Date 3- 101 _2 <br /> Payment Type CCInvoice# Check# Received ey: <br /> EHD 4&02-025 1L 2 2y 1 Q S 2�2 SR FORM(Golden Rod) <br /> REVISED 11/1712003 (� <br />