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DocuSign Envelope ID: 1D6BO063-0D713-4AD8-A2CA-96EEB7B3AF5A <br />AN JOAQUIN UUUNT Y ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # <br />1 ---1, '0 <br />SERVICE REQUEST # <br />S(zTeaociqci <br />OWNER/OPERATOR meytal Nai M CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS 3201 <br />Street Number Direction <br />Benjamin Holt Dr cfe, 100 Street Name <br />Stockton <br />City <br />95219 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Ex-r. <br />( ) 8186028889 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME GARY FITZGERALD CONSTRUCTION <br />PHONE # <br />( 1 <br />E XT <br />HOME or MAILING ADDRESS 5721 TOBIAS AVE <br />FAX # <br />5721 <br />( ) <br />Ow SHERMAN OAKS STATE CA ZIP 91411 <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 FtuDitmAkijaaar <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. <br />TYPE OF SERVICE REQUESTED: T. ,r-r-. SI es14•Kek-e -(--7,--04 (-(247e/e-V-ea <br />COMMENTS: <br />I <br />_ <br />--I--- rn 1 ()/1 el &V\ 01 <br />PAYMENT <br />RECEIVED <br />JUL 2 1 202 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMEN r <br />ACCEPTED BY: EMPLOYEE #: DATE: '1,•15;_ri..3 <br />ASSIGNED TO: kali fe-Ae---"" EMPLOYEE #: DATE: i ..-11.-0...+S <br />Date Service Completed (if already completed): SERVICE CODE: sr-2....,2 PIE: 0( <br />Fee Amount: L.-f -Li — Amount Paid E7. Payment Date <br />1//2 <br />Payment Type V LS n_ Invoice # Check ,,-' <br />4 <br />Received By: <br />END 48-02-025 <br />REVISED 11/17/2003 <br />(-°"F /(6)61 V /24-(2,02 SR FORM (Golden Rod) <br />P12 olp2-A <br />7/25/2023 <br />APPLICANT'S SIGNATURE: DATE: <br />73581E1DC7F482.. <br />PROPERTY / BUSINESS OWNERD OPERATOR / MANAGER UOTHER AUTHORIZED AGENT El agent