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P(� s ob3� <br /> DocuSign Envelope ID:5C8EDB77-5F19-4CBC-AB78-76C711268E10 <br /> aA1N JUAQU1N k—OUN-1-Y EN VIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant �Ip •T'-T S9.cLob--�CA <br /> OWNER/OPERATOR <br /> Shivendra Basnet CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> The Everest Momo LLC <br /> SITE ADDRESS 3200 Naglee Road Tracy 95304 <br /> Street Number I Direction Street Name City L Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1593 Monterey Hwy <br /> Street Number Street Name <br /> CITY San Jose STATE CA Zip 95110 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 4M 991-2347 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Shivendra Basnet CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> The Everest Morro LLC ( 408 ) 991-2347 <br /> HOME or MAILING ADDRESS 1593 Monterey Hwy FAX# <br /> ( ) <br /> CITY San Jose STATE CA ZIP 95110 <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,STATE and FEDERAL laws. <br /> D—Signed by: <br /> APPLICANT'S SIGNATURE: r 5H1VENaRA BAMT DATE: 04/13/2024 <br /> PROPERTY/BUSINESS OWNER OPE 11A'iPdWY GT.&AGER 0 OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorizaon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicaIle, 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 th^ea same time it is <br /> provided to me or my representative. ry Y <br /> TYPE of SERVICE REQUESTED: Change of ownership inspection F/V <br /> COMMENTS: APR �D?y <br /> sq N OAQ1j <br /> HEq�TH 0 PART/p L Y <br /> T <br /> ACCEPTED BY: fT EMPLOYEE#: DATE: <br /> ASSIGNED TO: ►l� i� EMPLOYEE#: DATE: �� •�L6� <br /> (6vZFDate Service Completed (if already completed): SERVICE CODE: P/E: (602— <br /> Fee <br /> ee Amount: I _ Amount Paid )`62.Uo Payment Date 7 2 <br /> Payment Type ` I Invoice# Check# 17 7 7 TSS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ( � - 7U <br />