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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 p SERVICE REQUEST# <br /> FULL SERVICE RESTAURANT FA0007377 <br /> OWNER I OPERATOR <br /> SS <br /> ZENAIDA D GUIZAR ESTRADA CNECN It BILL NG ADDRE <br /> FAm"NAME MIS DELICIA'S TAQUERIA INC <br /> SITEADDRESS 3200 NAGLEE RD STE 612 TRACY 95304 <br /> SlreeI NYTEer Dir¢tlon Slnet Name <br /> CRY Zia Code <br /> HOME Or MAILING ADDRESS (It Different from Site Address) 641 WADDELL WAY <br /> street Nurnwr St e N me <br /> Cm MODE5T0 STATE CA ZIP 95357 <br /> PHONE 11 EV' APN# LAND USE APPLICATION# <br /> 1 559 17011-4090 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQ CONTRACTOR <br /> D GUIZAR ESTRADA CHECK If BILLING ADDRESS <br /> IT <br /> LPHONE# EV' <br /> BUSINESS NAME MIS DELICIA'S TAQUERIA INC 559 1 706-4090 <br /> HOME Or MAILING ADDRESS FA%# <br /> 641 WADDELL WAY I ( I <br /> Cm MODESTO STATE CA ZIP 95357 <br /> BILLING ACKNONAILEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of some, P <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I IEALrli DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. RFS M<t y <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> JU <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. 0 C C•• <br /> APPLICANT'S SIGNATURE: 24iA ILL DATE: 0 LLSAN/Oq qUr y 1022 <br /> PROPERTY/BUSINESSOWNERd OPERATOR I MANAGER ❑ OTHER AVTROmzED AGENT❑ yEA/TrRON <br /> D CON <br /> V T,. <br /> IfAPPL/CANTis not lAe B/LIJNGPARTI:proof of authorization to sign is required Tlrl, CP rA ,r111" <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the A11V R Nev. <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirunmentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTti DEPARTMENT as Soon as it Is available and at the some time it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: NAME CHANGE,AND OWNER CHANGE TO PERMIT <br /> COMMENTS: <br /> PLEASE CHANGE THE NAME OF THE BUSINESS AND OWNER ON THIS PERMIT ID#PT0008807,NEW <br /> BUSINESS NAME IS MIS DELICIA'S TAQUERIA INC.NEW OWNER IS ZENAIDA D GUIZAR ESTRADA. <br /> ACCEPTED BY: Vtrq es c� EMPLOYEE#: DATE: <br /> ASSIGNED TO: Lrk tr( S EMPLOYEE#: DATE:"7 --( <br /> Dale Service Completed (it already completed): SERVICE CODE: b PIE: �/v2 <br /> Fee Amount: Is-,6 ,UO Amount Pa' `Y�,,6)4-,5 � Payment Dale V6 ZZ <br /> Payment Type �(� Invoice# Check# !7 b�.�tjS2,., Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />