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provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: PLAN CHECK FOR NEW COMMERCIAL HOOD <br />COMMENTS: <br />electronic <br />OC T <br /> , , N' :21:7:1 01 <br />; <br />,IEENVIRONMENTA <br />ALTH DEPARTME <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 10-27-22 <br />ASSIGNED TO: Gehane Fahmy EMPLOYEE #: 8788 DATE: 10-27-22 <br />Date Service Completed (if already completed): SERVICE CODE: 061 PIE: 1601 <br />q.-/(-44:7 Fee Amount: 468 Amount Paid i Li e6 __ Payment Date 106 <br />Payment Type Vt5A0t- Invoice # Check # Received By: A-14 <br />PA Y MIT <br />022 <br />KOlti9 K2 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />MARKET <br />FACILITY ID # SERVICE REQUEST <br />S600S5qS <br /># <br />1 <br />OWNER! OPERATOR <br />NASR ALESHMALI <br />CHECK if BILLING ADDRESS <br />FACILITY NAME JIMMY'S MARKET <br />SITE ADDRESS <br />2260 Street Number <br />E <br />Direction <br />YOSEMITE AVE. <br />Street Name <br />MANTECA co 95336 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />SAME Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />( 209 ) 483-1661 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />NASR ALESHMALI CHECK if BILLING ADDRESS <br />BUSINESS NAME JIMMY'S MARKET PHONE <br />( 20 ) 483-1661 <br />EXT. <br />HOME or MAILING ADDRESS 2260 E. YOSEMITE AVE. FAx# <br />( / <br />CITY STATE CA ZIP 95336 <br />BILLING ACKNOWLEDGEMENT: 1, 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 identif d on this form. <br />I also certify that I have prepared this application and at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FJ RAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER014 <br /> <br />DATE: 10/25/2022 <br />OPERATOR / IANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING P1i Tr proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFOR ATION: 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 />EHD 48-02-025 <br />REVISED 11/17/2003 <br />payment 151983266 <br />SR FORM (Golden Rod)