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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # SERVICE REQUEST # <br />9R OD'3 Sg -7-01 <br />OWNER/OPERATOR <br />Gurjit Khehra CHECK if BILLING ADDRESS <br />FACILITY NAME Zaika Indian Bistro & Bar <br />SITE ADDRESS 890 <br />Street Number Direction <br />Lifestyle Street, Suite #510 <br />Street Name <br />Manteca <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 498 <br />Street Number <br />W. Callado Ct. <br />Street Name <br />Crrv STATE ZIP Tracy CA 95391 <br />PHONE #1 EXT. <br />( 510) 309-9018 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Gary Ward CHECK if BILLING ADDRESS <br />BUSINESS NAME VirTek Design PHONE # <br />( 707) 291=1512 <br />Exr. <br />HOME Or MAILING ADDRESS <br />4505 Pacific Street <br />FAX # <br />( ) <br />CITY Farmington STATE NM ZIP 87402 <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, ST ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> 61.2aiLd <br /> <br />DATE: <br /> 10/5/2022 <br />PROPERTY! BUSINESS OWNER 0 OPERAT / MANAGER 0 OTHER AUTHORIZED AGENT Ca <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Designer <br />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 t ne time it is <br />provided to me or my representative. <br />'4.- <br />TYPE OF SERVICE REQUESTED: <br /> <br />Il b <br />COMMENTS: Ot7 0 p <br />Health Dept. Plan Check. eletronic S'Ipkiog <br />0 2022 <br />HP -A/Viflo QU1/4 <br />A17-xl/i)7-,,, <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 10-6-22 <br />ASSIGNED TO: Gehane Fahmy EMPLOYEE #: 8788 DATE: 10-6-22 <br />Date Service Completed (if already completed): SERVICE CODE: 523 P I E: 1601 <br />Fee Amount: 468 Amount Paid 0 4/6,3: OD Payment Date <br />Payment Type Cizail-1-- Invoice # Check # 1Ls-7 034s.2„s-- Received By:(825 <br />SR FORM (Golden Rod) payment confirmation 151036565 END 48-02-025 <br />REVISED 11/17/2003