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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S VICE REQUEST# <br /> Restaurant S� <br /> OWNER I OPERATOR CHECK It BILLING ADDRESS❑ <br /> Valley Diner Management, Inc. <br /> FACILITY NAME <br /> Denn 's <br /> SITEADDRESs 4747 Pacific Ave Stockton 94538 <br /> Street Number o street a Il zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3550 Mowry Ave <br /> Street Number Street Name <br /> CITY Fremont STATE CA Zip 94538 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (510) 792-3393 <br /> PHONE#2 Ev. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR William Ross <br /> CHECK It BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Ext. <br /> Quality Choice Construction (702) 641-2400 <br /> HOME or MAILING ADDRESS FAx# <br /> 2755 S. Nellis Blvd. Suite#10 <br /> ( 7 ) 641-2400 <br /> "I Las Vegas STATE NV ZIP 89121 <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 1 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: � i a_1_ DATE: 6/3/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT® Representative <br /> 9'APPL/CANT 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/s'yyGG assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at lht 1i'J54 Mrr��is <br /> provided to me or my representative. �e �'Vy�/ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 8 <br /> hF0�tico <br /> Fpo�� <br /> YgRT�� <br /> 17 <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 6_28_22 <br /> ASSIGNED TO: Lydia Baker EMPLOYEEM 9818 DATE: 6-28-22 <br /> Date Service Completed (If already completed): SERVICE CODE: 523 P l E: 1601 <br /> Fee Amount: 456 Amount Pal nT payment Date 22 <br /> Payment Type V;:56-- Invoice# CheckC#•��145-0/c7 S Received By: <br /> EHD 48-02-025 payment confirmation 145019945 / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />