Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast-food restaurant ' 1�O1tt32.m SRW��_I9(O8 <br /> OWNER/OPERATOR Central Valley Tacos, LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Del Taco 720 <br /> SITE ADDRESS 1194 East Yosemite Ave. Manteca 95337 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 44816 S. Grimmer Blvd. <br /> Street Number Street Name <br /> CITY Fremont STATE CA ZIP 94538 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510 )490-9717 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( 877)202-1981 x434 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Devika Sagar CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Central Valley Tacos, LLC 510 490-9717 <br /> HOME or MAILING ADDRESS 44816 S. Grimmer Blvd. FAx# <br /> CITY Fremont STATE CA ZIP 94538 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HI AL-rii DEPA RTMEN'r 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: Z�>ez'4 '�� DATE: 04/18/2024 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT 13 <br /> //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. <br /> TYPE OF SERVICE REQUESTED:Food Service Environmental Health Permit RE T <br /> lw- <br /> COMMENTS: <br /> CHANGE OF OWNERSHIP APR 22 X024 <br /> SAN NE L Ng SPAENTO NTy <br /> DEPARTII�ENT <br /> ACCEPTED BY: L C X EMPLOYEE#: DATE: <br /> ASSIGNED TO: (J� EMPLOYEE#: DATE: 2 3 LL <br /> Date Service Complete (if already completed): SERVICE CODE: P I E: 4 0 <br /> Fee Amount: 162— Amount Paid /6 b 7) 1Payment Date 2 <br /> Payment Type Invoice# Check# SOZ1 738(p Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 S' <br />