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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant �pa5�-l� Mq � <br /> OWNER i OPERATOR <br /> Eva Elizabeth Flores-Ramirez CHECK If BILLING ADDRESS <br /> FACILITY NAME La Casa Castrejon Bar & Grill <br /> SITE ADDRESS 14814 Thornton Rd Lodi 95242 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 31710 Determination Dr <br /> Street Number Street Name <br /> Cm Tracy STATE CA Zip 95304 <br /> PHONE#1 EX7, APIA# LAND USE APPLICATION# <br /> ( 209 ) 229-0165 <br /> PHONER Ex . BOS DISTRICT LOCATION CODE <br /> (209 ) 990-4584 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Eva Elizabeth Flores-Ramirez CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> La Casa Castrejon Bar & Grill (209 ) 229-0165 <br /> HOME or MAIUNG ADDRESS FAX# <br /> 31710 Determination Dr ( ) <br /> CITY Tracy STATE CA 'P 95304 <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 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 SIGNATURRE: VOA F e)m DATE: <br /> PROPERTY/BUSINESS OWNER101 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/(_ANT 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 environment/j'te assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and tl} C it is <br /> provided to me or my representative. SFr, T <br /> TYPE OF SERVICE REQUESTED: Change of Ownership Inspection A/1 VICZ0 <br /> COMMENTS: CO <br /> 2! <br /> �9CT}i p N'N�, �7Y <br /> ACCEPTED BY: ��" S,, EMPLOYEE#: DATE: 7 2 <br /> AsSIGNEDTO: WWWWS (D y_ , EMPLOYEEM DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Oen P I E: <br /> Fee Amount: 5 U Amount Paid I a Payment Date <br /> qP <br /> Payment Type O 1 Invoice# C(/heck# 12 �q Received By: <br /> EHD 4&02-025 'Y+D) SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> leo ` 3 ws <br />