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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property MARKET FACILITY ID # SERVICE REQUEST S6oncis1 # OWNER! OPERATOR NASR ALESHMALI CHECK if BILLING ADDRESS FACILITY NAME JIMMY'S MARKET SITE ADDRESS 2260 Street Number E Direction YOSEMITE AVE. Street Name MANTECA CRY 95336 Zlp Code HOME or MAILING ADDRESS (If Different from Site Address) SAME Street Number Street Name CITY STATE ZIP PHONE #1 EXT. ( 209 ) 483-1661 APN # LAND USE APPLICATION # PHONE #2 Err. ( ) BOS DISTRICT LOCATION CODE . CONTRACTOR / SERVICE REQUESTOR REQUESTOR NASR ALESHMALI CHECK If BILLING ADDRESS BUSINESS NAME JIMMY'S MARKET PFigN ( " ) 483-1661ik4 EXT. HOME or MAILING ADDRESS 2260 E. YOSEMITE AVE. PAX # ( ) CITY STATE CA ZIP 95336 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identif d on this form. 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 COUNTY Ordinance Codes, Standards, ST ATE and F RAL laws. APPLICANT'S SIGNATURE: PROPERTY/BUSINESS OWNERDB OPERATOR/ IANAGER OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING P TI' proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFOR ATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: PLAN CHECK FOR NEW COMMERCIAL HOOD tC OC .I 2 COMMENTS: electronic 1 1:4 ANIN.io 40 u:71 HEAL ENVIRONMENTA TH DEPARTME ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 10-27-22 ASSIGNED TO: Gehane Fahmy EMPLOYEE #: 8788 DATE: 10-27-22 Date Service Completed (if already completed): SERVICE CODE: 061 PIE: 1601 Fee Amount: 468 Amount Paid di ta -- Payment Date ,..-- . Payment Type Vt/510t--- Invoice # Check # Received By: A,e4 022 TV maw de 0,24-072-aa-a.:1?(47,61,) DATE: payment 151983266 SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003