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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Mobile Food Trailer <br />FACILITY ID # SERVICE REQUEST # <br />SIZ(481-CDC11 <br />OWNER/ OPERATOR <br />Lisa Weaver CHECK if BILLING ADDRESS <br />FACILITY NAME Oozey B's LLC <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 5229 <br />Street Number <br />Quash nick Road <br />Street Name <br />CITY <br />Stockton STATE <br />CA <br />ZIP <br />95212 <br />PHONE #1 Exr. <br />(209) 207-4222 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(209) 326-1126 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />Lisa Weaver CHECK if BILLING ADDRESS rd <br />BUSINESS NAME PHONE Oozey B's LLC # <br />(209) 207-4222 <br />ExT. <br />HOME or MAILING ADDRESS 5229 Quashnick Road FAX # <br />( ) <br />CITY Stockton STATE CA zip 95212 <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 TE.and FEDERAL law <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />. imrivi <br />TYPE OF SERVICE REQUESTED: Mobile Food Trailer inspection REC A <br />E-I COMMENTS: VE' Newly manufactured food trailer / never been used. Insignia certified. AUG 2 3 2023 <br />ca—t 1 9 u r r SAN J04 Qu <br />"4 1-TH Deb'wEN T4 L. <br />'ARTroptv <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 8 -23 -23 <br />ASSIGNED TO: to be assigned EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 523 P/ E: 1601 <br />Fee Amount: 486 Amount Paic# `716. OC) Payment Date 2/23/23 <br />Payment Type 0.59_ Invoice # Check # /,7 437 26., — Recei d By: 643 <br />EHD 48-02-025 <br />REVISED 11/17/2003 payment 167637269 <br />SR FORM (Golden Rod) <br />61/31-vAza <br />Title