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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID # <br />C_ C-'-) I u -+ 2;4- <br />SERVICE REQUEST # <br />kz.:3(f)(D BT-4 (P-4 <br />OWNER! OPERATOR THE CAJUN SPOT CHECK if BILLING ADDRESS <br />FACILITY NAME <br />THE CAJUN SPOT 3242 W GRANT LINE RD TRACY, CA 95304 <br />SITE ADDRESS 3242 <br />Street Number <br />W <br />Direction <br />GRANT LINE RD <br />Street Name <br />TRACY <br />City <br />95304 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exi. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQ1LTESTOR <br />REQUESTOR <br />Persis Restaurants Inc CHECK if BILLING ADDRESS <br />BUSINESS NAME PARADISE BIRYANI POINTE PHONE # <br />408.823.5754 <br />I .) <br />EXT. <br />HOME 01-MAILING ADDRESS 2443 BASSWOOD DR <br />FAX # <br />( ) <br />CITY SAN RAMON SE CA ZtP 94582 EMAIL sudababu@gmail.com <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 ENVIR ON MEN TAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br />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 />APPLICANT'S SIGNATURE: 5 12.-"'"' 27'4'4 DATE: 02/26/2024 <br /> <br />PROPERTY/BUSINESS OWNER Si OPERATOR/MANAGE D' <br />If APPLICANT is not the BILLING PANTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: Men applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is proild to me Or my <br />representative. Y • <br />TYPE OF SERVICE REQUESTED: Change of Ownership Health Inspection r.< CEivE D <br />FEBCOAAMEN TS : 2 6 2024 <br />SAN j0,40, is <br />, , ENVIR oGN,C,OUNTy rrEALT H DEp"A"-rx 1 ,1 `4,TA L <br />--, mENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />Ass ION ED TO: L;,---, \r --, (7.. r c - - EMPLOYEE #: ,-__k --Ci!) C i DATE: 2 _ 2 6 ,_ 2_ L <br />Date Service Completed (if already completed) SERVICE CODE: 01Q \ PIE: <br />Fee Amount: ‘ 2 _ Amount Paid I "2 — Payment Date 2 — 2 <br />Payment Type <br />C c <br />Invoice # Check # / 77 64,,2:75-2___ Received By: dirb.. <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />OTHER AUTHORIZED AGENT ID <br />03/22/23