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FACILITY ID # <br />TracyStreet Number City <br />Street Number <br />City State <br />APN#Ext.Land Use Application # <br />EmailExt.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Ext. <br />City 91768Ganesha Hills CA <br />05.10.2024APPLICANT’S SIGNATURE: Date: <br />to me or my <br />Type of Service Requested: <br />Comments:Plan review <br />Vidal Pedraza 5-16-24Employee#: 6213 Date:Accepted By: <br />Kadeanne Linhares 5-16-24Employee #:4589 Date:Assigned to: <br />P/E: 1601Service Code:523Date Service Completed (if already completed): <br />Payment DateFee Amount: <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />Owner/Operator <br />Mohammed Zubair <br />Type of Business or Property <br />Restaraunt (30 Occupants) <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />SERVICE REQUEST# <br />APa40O3<T5 <br />Facility Name <br />Deccan Morsels <br />SiteAjjdress <br />Street Name <br />Zip <br />13 4-0 Hi IICreS~t T>r. <br />State A Zip <br />Requestor <br />Nidal Hamida_____ <br />Business Name, .Hamida Architects <br />Home or Mailing Address <br />Phone #1 <br />( ) <br />Check if Billing Address D <br />Phone #2 <br />() <br />Check if Billing Address d <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 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^nd Federal laws. <br />486 <br />Payment Type <br />Payment 181553329 <br />Grant Line Rd, __________________Street Name <br />Home or Mailing Address (If Different from Site Address) <br />W, Directfon <br />Property I Business Owner Operator / Manager Other Authorized Agent EK <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 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 i^gpyi^d^L. <br />representative. <br />c5l2-ll'2.tA <br />Received By: <br />Phone # <br />(323)678.1463 <br />Fax# <br />( )_________ <br />Emah. g-1758 <br />Amount Paid —