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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME ELEVATION DESIGN + CONSULTING ERVICE REQUEST # GROCERY MARKET FAX# 615 13TH STREET, SUITE B5 S m4w4 OWNER/ OPERATOR Date Service Completed (if already completed): SAVI'S LLC., 1314 COW ST. MOUNTAIN HOUSE, CA. 95391 CHECK If BILLING ADDRESS❑ FAcUTYNAME SAVI'S INDIAN GROCERIES Fee Amount: SITE ADDRESSw 1 Payment Date GRANTLINE ROAD TRACY 95376 3280 Street Number Direction Street Name city A"Wde HOME or MAILING ADDRESS (If Different from Site Address) /1� �,A Street Number Street Name P9 CITY STATE zip CE,I i PHONE#1 Exr. APN# LAND USE APPLICATION # SAIV4," ( 510 ) 378-547 238-600-42 ENVIROA/1*$� PHONE #2 Exr. BOS DISTRICT AITy NAf � ( ) CONTRACTOR / SERVICE REQUESTOR VT �D bry %'p MKTMENi REQUESTOR SABINO URRUTIA CHECK If BILLING ADDRESS BUSINESS NAME ELEVATION DESIGN + CONSULTING PHONE III R, HOME or MAILING ADDRESS FAX# 615 13TH STREET, SUITE B5 ( ) CITY MODESTO STATE CA ZIP 95354 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE.y:12/14/21 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENTODESIGNER If APPLICANT is not the BILLING PARTY proof of authorization t0 sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: EQUIPEM ENT/ INTERIOR FINISH COMMENTS: FACILITY HAS AN EXISTING 3000 GALLON GREASE INTERCEPTOR AT THE EAST END OF BUILIDNG ACCEPTED BY: IL ix -p y-6 ,1 n EMPLOYEE #: � (v �i3 DATE: '` ZZ ASSIGNED TO: h , 1L � ' L EMPLOYEE #: Int Q DATE: 1 ZZ Date Service Completed (if already completed): SERVICE CODE: P E: 6 Fee Amount: Amount Paid t.00 1 Payment Date Payment Typel*_ Invoice # Check # �JIO �gOZ Received By: REVISED 110 17/2003 "1 13 boo W 2Z SR FORM (Golden Rod)