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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICk REQUEST# <br /> Restaurant �� �tS ��� Wa /fl�f(� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Sourdough & Company <br /> SITE ADDRESS 959S Tracy Blvd., Tracy 95376 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 793 S Tracy Blvd#108 <br /> Street Number Street Name <br /> CITY Tracy STA�EA ZIP 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION <br /> ( ) <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Alik Oganesyan CHECK If BILLING ADDRESS <br /> BUSINESS NAME RCI Integrated Construction Inc PHONE# En. <br /> 9 916-6204065 <br /> HOME or MAILING ADDRESS FAX# <br /> 8215 Obsidian Bay Ct, I I <br /> CITY Sacramento STATE CA ZIP 95829 <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 /> I 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 anEDE L laws. <br /> APPLICANT'S SIGNATURE: / DATE:_ <br /> PROPERTY/BOs1NESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Operator's Rep <br /> IfAPPL/CANT is not the B/LLiNG PARTY proof of authorization to sign is required Title <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 time it is <br /> provided to me or my representative. 1 ,., P <br /> TYPE OF SERVICE REQUESTED: ��C Q Ak I all C Ae <br /> 11 0E- <br /> %COMMENTS: JAN <br /> Oy <br /> Hl qE TMD Ng '"4147- <br /> ACCEPTED <br /> C 1J1� <br /> TME <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �`N \ `LT,�1°5 EMPLOYEE#: DATE: t—(-A- 22 <br /> Date Service Completed (if already Completed): SERVICE CODE: <br /> PIE: <br /> 3 PIE: b�1 <br /> Fee Amount: ��4 Amount Pai /79 . Payment Date ZZ <br /> Payment Type ' Invoice# Check# �c.3�t�� G I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �0 0 22 O <br />