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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# JERVICE REQUEST# <br /> Restaurant `J'Koo01 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Sourdough & Company <br /> SITE ADDRESS 3280W Grant Line Road, Tracy 95304 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1961 Basque Dr. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95304 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Alik Oganesyan CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME RCI Integrated Construction Inc PHONE Ex <br /> 916-620-4065 <br /> HOME Or MAILING ADDRESS FAx# <br /> 8215 Obsidian Bay Ct, ( ) <br /> CITY Sacramento STATE CA ZIP 95829 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 anFEDE L laws. <br /> APPLICANT'S SIGNATURE: Qum" DATE:_ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® _ Operator's Rep <br /> /f APPLICANT 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. Haka OV ,C rJlv�- <br /> TYPE OF SERVICE REQUESTED: E <br /> llilif-r <br /> COMMENTS: EL) <br /> electronic MAY 09 <br /> SAN M 201? <br /> ENV/ROU/N CCU <br /> HEALTH OE gRTTAL n <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 5-9-22 <br /> ASSIGNED TO: Kadeanne Linllares EMPLOYEE#: 4589 DATE: 5-9-22 <br /> Date Service Completed (if already completed): SERVICE CODE: 061 PIE: 1601 <br /> Fee Amount: 456 Amount Paid Payment Date - ?OZZ <br /> Payment Type 50— Invoice# Check# Received By: <br /> EHD 48-02-025 payment confirmation SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />