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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # ExT• <br />SERVICE REQUEST # <br />Restaurant <br />CITY STATE ZIP <br />OWNER / OPERATOR <br />Raman Dhillon <br />CHECK If BILLING ADDRESS <br />F cl mNA <br />kleherryI <br />ACCEPTED BY: Vidal Pedraza <br />SITEADDRESS 10718 <br />EMPLOYEE M 6213 <br />Trinity Parkway, <br />ASSIGNED TO: Stephanie Ramirez <br />Stockton <br />95219 <br />Street Number <br />Direction <br />Street Na a <br />SERVICE CODE: 523 <br />Ci[ <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Amount Paid <br />qS 6 y� <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE V E4 <br />APN # <br />LAND USE APPLICATION # <br />6161865-805 <br />PHONE #2 Em <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />I <br />PHONE # ExT• <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY STATE ZIP <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: IC, rI U t elm DATE: 9/22/21 <br />PROPERTY/ BUSINESS OWNERX OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />If 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. PQYMe r t.. <br />TYPE OF SERVICE REQUESTED: Food Plan Check <br />EcE <br />COMMENTS: <br />SEP 2 2 2021 <br />SAN JOAQUIN CO UNTy <br />HEALTH DE ARTM <br />NT <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE M 6213 <br />DATE: 9-22-21 <br />ASSIGNED TO: Stephanie Ramirez <br />EMPLOYEE #: 1084 <br />DATE: 9-22-21 <br />Date Service Completed (If already Completed): <br />SERVICE CODE: 523 <br />P 1 E: 1601 <br />Fee Amount: 456 <br />Amount Paid <br />qS 6 y� <br />Payment Date <br />Payment Type CY <br />Invoice # <br />Check # � <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden Rad) <br />REVISED 11/1712003 ^V'r 62A?5f <br />