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SAN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Commercial Bar/Restaurant <br />FACILITY ID # <br />[5t4L(C <br />SERVICE REQUEST # <br />SW) 8(0 -1-(d-7- <br />OWNER / OPERATOR Jonathan Hernandez CHECK if BILLING ADDRESS <br />FACILITY NAME Black Rabbit <br />SITE ADDRESS 2353 <br />Street Number Direction <br />Pacific Ave <br />Street Name <br />Stockton <br />City <br />95204 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 4219 <br />Street Number <br />Pinehurst Cir. <br />Street Name <br />CITY Stockton STATE C A ZIP 95204 <br />PHONE #1 Er-. <br />( ) (209)643-3629 <br />APN # <br />11335424 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Pete Rosado CHECK if BILLING ADDRESS <br />BUSINESS NAME LDA Partners PHONE # EXT. <br />(209 )943-0405 <br />HOME or MAILING ADDRESS FAX # <br />222 Central Ct ( 209 ) 943-0415 <br />CITY Stockton STATE CA ZIP 95204 <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 FE ERAL laws. <br />APPLICANT'S SIGNATURE: <br />(*.k." <br />DATE: 5/25/2023 <br />PROPERTY / BUSINESS OWNERld OPE • ILK i • AN • GER El OTHER AUTHORIZED AGENT 0 <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 tiii)4it is <br />provided to me or my representative. <br />vpd,, <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />TYPE OF SERVICE REQUESTED: <br />FIcio, <br />ft ) ‘C-c--p--ct1W >i<t4--(46tY Xek .+0 <br /> <br />4 :I <br />klif26, COMMENTS: f---bieLt.4....cr A <br /> <br />S L .--„4-7 64, g <br />'1<T/46'0451N cs <br />416-4 <br />ACCEPTED BY: Ca iitAA 'e S C- 0 <br />EMPLOYEE #: DATE: 5---,-- 2 & .._23 <br />ASSIGNED TO: ,4-1 ke ti-- EMPLOYEE #: DATE: C - -2.4.:, -- 413 <br />Date Service Comple ed .(if already completed): SERVICE CODE: 52_3 P/E 401_ <br />Fee Amount: -17 '• Amount Paid ifkiii-6 OO Payment Date 524 2.3 <br />Payment Type Vi&c_ Invoice # Check # i 6 2:75--(„ /24— — Received By: