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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 />C0051-o id <br />SERVICE REQUEST # <br />Sk 00R_scos z_ <br />OWNER / OPERATOR <br />Mike Peltekci CHECK if BILLING ADDRESSO <br />FACILITY NAME <br />Charleys Philly Steaks <br />SITE ADDRESS <br />3010 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 />Crry STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT <br />( ) <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Rachael Burdon CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />StudioRG <br />PHONE # <br />(516- ) <br />EXT. <br />669-4762 <br />HOME or MAILING ADDRESS <br />1 Huntington Quadrangle Ste 2CO3 <br />FAX # <br />( 1 <br />Cm, <br />Melville <br />STATE <br />NY <br />ZIP 11747 <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 />APPLICANT'S SIGNATURE: <br /> <br /> DATE: 08/05/2022 <br /> <br />PROPERTY! BUSINESS OWNERCI OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT X Expediter <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 availab e gat same time it is <br />provided to me or my representative. PA <br />TYPE OF SERVICE REQUESTED: RECEIVED <br />COMMENTS: <br />ENVIRONMENT <br />JOAQUIN <br />0 i9N 2022 <br />SAN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: 2 , 1 / DATE: S t ?/ iz <br />ASSIGNED TO: (64:4_,C04(.4tee„.. bc 4,.., 44041 EMPLOYEE #: (....4 5 ,g 9 DATE: / g,/ <br />Date Service Completed (if already completed): SERVICE ClIODE: ,4---,6 51, - PIE: i (0011 <br />Fee Amount:* 1--i • ---- Amount Paid q 6 g Payment Date S 6172_2_ <br />Payment Type C.L._ Invoice # Check # Received By,..4.----- <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) pa,,,.441- I Lf7 ocl 31 v(zoc,oi23