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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gree w ✓Q tl/C7 ���J <br /> OWNER/OPERATOR CHECK N BILLING ADORESS❑ <br /> Janette Escobal <br /> FACILITY NAME <br /> The Grant Bar& Lounge LLC <br /> SITE ADDRESS 2706 Pavillion Prkway Tracy 95376 <br /> Street Number I Dl'.Ot n CIV ZIDCod. <br /> HONE Or MAILING ADDRESS (If Diffemnt from Site Address) 25164 Copa Del Oro Dr.#201 <br /> Sheet Number <br /> Stm.t Name <br /> CIN STATE zip <br /> Hayward CA 94545 <br /> PHONE#i E.T. APN# LAND USE APPLICATION# <br /> ( 510) 415-7484 <br /> PHONER Ext. BOS DISTRICT LOCATION CODE <br /> 1 510) 565-5735 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> BUSINESS NAME pHONE# Ev' <br /> HONE or MAILING ADDRESS FAx# <br /> CITY STATE LP <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 ENV NM <br /> MENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my businesses i fled on this form. <br /> I also certify that I have prepared this applic d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S ATE FEDERAL I <br /> APPLICANT'S SIGNATURE: ATE: 513Zt)8V2� <br /> PROPERTY/BUSINESS OWNER O OR I MANAGER OTHER AUTHORIZED AGENT <br /> #APPLICANT is not the Rn 'G PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE ORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize he release of any and all results, geotechnical data and/or environmentalisite assessment <br /> information to the SAN IOAQUIN COU TY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the une time it is <br /> provided to me or my represent'ati've. { n A <br /> TYPE OF SERVICE REQUESTED: !V Q t.(I C a <br /> COMMENTS: <br /> NY <br /> OA QU/IV <br /> HfSAIVj 2Z2 <br /> gLTHOE; COUIV <br /> R10-4 <br /> ACCEPTED BY: �Gc✓dK L 5 c EMPLOYEE M DATE: —ZZ <br /> ASSIGNED TO: ` C(V1e5 EMPLOYEE#; DATE: <br /> V I Z�� <br /> Date Service Completed (it already completed): SERVICECODE: C1 0 i( PIE; G 2 <br /> Fee Amount: /S'2��d Amount Pai �� Payment Date S T 2-2— <br /> Payment <br /> -Z <br /> Payment Type Vi��- Invoice# Check# 78 Received By: <br /> EHD 4&112-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> p�aS�11�13 <br />