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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant «�Uovi3I] Slebi) 8 -bq3 <br /> OWNER/OPERATOR <br /> Rosa Isela Sanchez and Alemandro Osuna CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Johnny. statirapt <br /> SITE ADDRESS 1 610 E Yosemite Ave Manteca , Ce 95336 <br /> Street Number Dlrecdon Street Name C L Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Sveet N. a <br /> CITY STATE Zip <br /> PHONE#1 Ex. APN 0 LAND USE APPLICATION# <br /> (209 ) 2399111 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (209 ) 4043573 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Rosa Isela Sanchez CHECK If BILLING ADDRESS <br /> BUSINESS NAME Johnny's Restaurant PHONE# En. <br /> 209 1 239 9111 <br /> HOME or MAILING ADDRESS 610 E Yosemite Ave Fax# <br /> 1 1 <br /> CITY Manteca STATE Ca Zip 95336 <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 /> 1 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: �,�/ �j -,,&4- _4+-`�L DATE: 3/20/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> LfAPPLICANT is not the BILLLNG 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 environmeenntaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ae time it is <br /> provided to me or my representative. 'l/M1' <br /> TYPE OF SERVICE REQUESTED: ,,n /V <br /> COMMENTS: l.y? � O" �w�r-r✓rf' <br /> / h ANrNOQ MRT�N?"04 vlV <br /> 7- <br /> ACCEPTED <br /> ACCEPTED BY: /.v EMPLOYEE#: g DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: 2 Z 2 <br /> Date Service Completed (if already completed): SERVICE CODE: G P 1 E: <br /> Fee Amount: Amount Pat �� Ul] Payment Datei�- <br /> Payment Type �, _ Invoice# Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17!2003 <br /> � n �I 2�5� t✓ <br />