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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTTT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n � ( <br /> Restaurant T L�I S DDD $ I 1 <br /> OWNER I OPERATOR <br /> Debby Bettencourt CHECK If BILLING ADDRESS <br /> FACILITY NAME Debby's Cuisine <br /> SITE ADDRESS Stanislaus Street Suite F Escalon 95320 <br /> 1429 Sbeel Number Direction Street Nama <br /> G <br /> zi cede <br /> HOME or MAILING ADDRESS (#Different from Site Address) 3848 McHenry Ave Ste 135#231 <br /> Strtet Number Street Name <br /> Cm Modesto STATE CA ZtP 95356 <br /> PHONE41 APN# LAND USE APPLICATION# <br /> (209 ) 620-3854 <br /> PHONE#P BOS DISTRICT LOCATION CODE <br /> (209 ) 804-8118 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Dn IO 'VC `�n�vT1 <br /> ( �V�/V �Tt.a' 1 L CHECK if BILLING ADDRESS <br /> BUSINESS NAME rr toa ,S C>-) <br /> G� .r�0 PHQM) <br /> HOME9MARNG ADDRESS Fo# <br /> ' 9 <br /> Ems. <br /> M flNe. S <br /> CRY " 03t-:)+D STATE CA ZIP S 3 S✓.� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operrator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENrAL HEALTN 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 prep azed appli uon and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Godes,S(a it rds, TATE d F• 12AI.laws. <br /> APPLICANT'SSIGNATU DATE: D J D�;L <br /> PROPERTY/BUSINESS OWNER OPFRATOR/MANAGER ❑ OrnER AUTIIORIzED AGENT❑ <br /> IJAPPL(cdNrisnoiihe BuuNCPA,R proof of authorization to sign is required Tir1r <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 Lime it is <br /> provided to me or my representative. AYIVIe <br /> TYPE OF SERVICE REQUESTED: Owner Transfer Inspection IVSD <br /> COMMENTS: APR 13 <br /> 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE; O'•'(1 r <br /> ASSIGNED TO: EMPLOYEE#: DATE: ?j 'Z <br /> Date Service Cam leted (If already completed): SERVICE CODE: C ((,7 p I E; <br /> Fee Amount / Payment Date <br /> , , Z <br /> 3.� <br /> Payment Type — Invoice# Check# 42—D�g 2g� Recely' By: <br /> EHDod)25 � 1 Z`� SR FORM(Golden <br /> REV R <br /> REVISEDSED 1111/17/2003 <br />