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pp, n S 2'1253 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ( 42 s--a,vr t9j45-:f <br /> OWNER/OPERATOR <br /> RTP Tracy INC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Round Table Pizza <br /> SITE ADDRESS Nag lee RD Tracy. 95304 <br /> 2511 Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.0 Box 1015 Street Number Street Name <br /> CITY Tracy STATE ZIP <br /> CA. 95378 <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> ( 510) 676-6160 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Yadwinder Khahira kVN0h\` ro"` CAYWN CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> Round Table Pizza 510). 676-6160 <br /> HOME or MAILING ADDRESS FAX# <br /> P.0 Box 1015 ( ) <br /> CITY STATE ZIP EMAIL <br /> Tracy CA. 95378 spkhahira@icloud.com <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 or activity <br /> 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 pnd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10/17/2023 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT ❑ Manager <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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS prov�ed to me or my <br /> representative. A �C <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: O D <br /> SAN�Cr 9 ?323 <br /> HFA Ty vl�Q �N)LI <br /> RN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: \^ A EMPLOYEE#: DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: O b 1 PIE: k\002 <br /> Fee Amount: \ \,0,2 r Amount Paid / Payment Date , 1 �> . <br /> Payment Type C C Pnvoice# Check# 17D433 O 3 Received By: <br /> b338�13 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />