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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />CHECK if BILLING ADDRESS❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />S�DUgLI'�-I)- <br />(1e„J <br />HOME or MAILING ADDRESS 1000 Corporate Center Dr., Ste 550 <br />OWNER/ OPERATOR <br />CITY Monterey Park <br />CHECK If BILLING ADDRESS <br />Victor Panaich (DV Pizza, Inc.) <br />FACILITY NAME Mountain Mike's Pizza <br />SITE ADDRESS 19677 <br />Mountain House Pkwy. <br />Mountain House <br />95391 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip C.de <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) 1594 <br />Wildplum Way <br />Street Number <br />Street Name <br />CITY Tracy <br />STATE CA ZIP 95376 <br />PHONE #1 Ems• <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 631-3219 <br />PHONIER EAT. <br />( ) <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Juan Rangel <br />CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME GWA Architecture, Inc. <br />PHONE #' <br />626 1 288-6898 <br />HOME or MAILING ADDRESS 1000 Corporate Center Dr., Ste 550 <br />FAx # <br />( ) <br />CITY Monterey Park <br />STATE CA ZIP 91754 <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: $—OR—va DATE: 09.14.21 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHERAUTHORIZED AGENT ® Associate <br />17APPLICANT is not the BILLING 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 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. <br />TYPE OF SERVICE REQUESTED: New Food Facility Plan Check 1V1F <br />COMMENTS: � V�D <br />sA SEP JO 2021 <br />NFAL NI) P EE 7 -AL <br />ACCEPTED BY: �y y.�µr„S EMPLOYEE#: DATE: 61_fs-2It <br />ASSIGNED TO: �..l�n yvr s EMPLOYEE #: DATE: 1 <br />�'1j "Z -i <br />Date Service Completed (if already completed): SERVICE CODE: .5 Z3 P / E. O <br />Fee Amount: S6 Amount Pai LF� / e O� Payment Date <br />Payment TypeInvoice # Check # Receiv d By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />I <br />SR FORM (Golden Rod) 5 <br />