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±C/JL <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />RESTAURANT <br />FACILITY ID # <br />SqUYS 5C/' <br /> SERVICE REQUEST # <br />i <br />OWNER / OPERATOR JASMANJIT SODHI 12 CHECK if BILLING ADDRESS <br />FACILITY NAME DRIPPIN CHICKEN <br />SITE ADDRESS 3099 <br />Street Number <br />N. <br />Direction <br />TRACY BLVD <br />Street Name <br />TRACY <br />City <br />95376 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />STATE <br />Street Name <br />CITY ZIP <br />PHONE #1 ExT. <br />( 209 ) 814-2525 <br />APN # I <br />214-18-41 <br />LAND USE APPLICATION # <br />PHONE #2 E. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS FAX # <br />( ) <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: JASMANST S0171-11 DATE: 09-15-22 <br />PROPERTY / BUSINESS OWNERS! OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICAN7' 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: PAYMENT <br />RECEIVED <br />COMMENTS: OCT 03 2022 <br />AN JOAQUIN cOUNTY <br />L NVIRONMENTAL <br />,Ii num DEPARTMENT <br />ACCEPTED BY: CCX ( ( -e sc p EMPLOYEE #: DATE: <br />ASSIGNED TO: L: \(\\f"\c A I 'QS EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 'S 22 PIE: \O 1 <br />Fee Amount: \A ,— Amount Paid /IL % _--- Payment Date )Q ( 3( <br />Payment Payment Type <br />V 1c7 A Invoice # Check # Received By: if-07 <br /> 9 0 s 1(3t)/24, SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003