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PO-0 S2 2 e_5,18 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CONCESSIONS <br />FACILITY ID # <br />'',‘ 1'(% / <br />SERVICE REQUEST # <br />Se)M-P33 <br />OWNER! OPERATOR <br />JAYS GOURMET LIMITED LIABILITY CO CHECK if BILLING ADDRESS <br />FACILITY NAME <br />TRACY SPORTS COMPLEX <br />SITE ADDRESS <br />955 Street Number Direction CROSSROADS DR otreet Name TRACY City 953117Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />880 W MOUNT DIABLO AVE. Street Number Street Name <br />CITY STATE ZIP <br />TRACY CA 95376 <br />PHONE #1 Err. <br />(2 o 7 ) 3q-cg E <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(9 25 ) 967-1E67 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />JERROD LAKEY CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( 209 ) 399-0888 <br />Err. <br />HOME or MAILING ADDRESS <br />880 W MOUNT DIABLO AVE. <br />FAX # <br />( ) <br />CITY <br />TRACY STATE CA ZIP 95376 <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 ATE and <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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 the same time it is <br />provided to me or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: i 41 '1/2 /7-1 <br />HEUER/EU <br />COMMENTS: FEB 2 1 2024 <br />SAN JOAQUIN COUNTY <br />ENVIRONNINTAL <br />HEALTH DEPART MEN' <br />ACCEPTED By: BY: (...___,, .„... r_A. .,e. EMPLOYEE #: DATE: <br />ASSIGNED TO: L---,•.--k 1,-,,,,.-,.e 5 EMPLOYEE #: DATE: 2-- <br />Date Service Completed (if already completed): SERVICE CODE: E.,)6 ( 13 1j:/6ey.)__ <br />--vv t/ , <br />By: <br />Fee Amount: / & .2, --- Amount Paid #/ a2 -- Payment Date 2-/'24 <br />Received Payment Type v )e-7 ict- Invoice # yre-K# il, LI ----gL n,S—. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER S' OPERATOR / MANAGER Ef <br />DATE: 24/2 V <br />OTHER AUTHORIZED AGENT 0 i0L/tiliti