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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # To -Go Restaurant - no indoor dining J SEC 0 I l SA N104QU/tV ?�2% E HEq4r�oARTM CNTy n cJ HOME or MAILING ADDRESS S q (J O OWNER/ OPERATOR ( ) N/A 0 Javier Llamas If CHECK if BILLING ADDRESS FACILITY NAME EI Grullito To -Go Restaurant PIE: 1601 Fee Amount: 456 Amount Paid 51600 RESS W 600 W. I Longview Ave Invoice # Stockton Received By: 95205 Street Number Direction Street Name city zip Cade HOME or MAILING ADDRESS (If Different from Site Address) 3941Angelina Lane Street Numb Street Name CITY Stockton STATE CA 71P 95212 PHONE#1 Eur' APN# LAND USE APPLICATION# ( 209 ) 688-7196 108-120-330 PHONE #2 ExT. ( ) SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Steven Torres, Architect CHECK if BILLING ADDRESS BUSINESS NAME A ex Architecture P J SEC 0 I l SA N104QU/tV ?�2% E HEq4r�oARTM CNTy PHONE# Ext. 209 1 662-4874 HOME or MAILING ADDRESS EMPLOYEEM 6213 FAX# 735 S. Shasta Ave ( ) N/A CITY Stockton STATE CA zIP 95205 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY/ BUstNESs OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® If APPL/CANT is not the BILLING PARTY proof of authorization to sign is required 11-30-2021 Architect Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. An. - _ TYPE OF SERVICE REQUESTED: COMMENTS: J SEC 0 I l SA N104QU/tV ?�2% E HEq4r�oARTM CNTy ACCEPTEDBY: Vidal Pedraza EMPLOYEEM 6213 DATE: 12-7-21 ASSIGNEDTO: Vidal Pedraza EMPLOYEEM 6213 DATE: 12-7-21 Date Service Completed (if already completed): If SERVICE CODE: 523 PIE: 1601 Fee Amount: 456 Amount Paid Date TD(o� / 7 .�-G Payment TypeVi Invoice # /Payment Check # /3S� g8 Received By: EHD 4e-02-025 Payment confirmation # 135688408 REVISED 11/17/2003 PP -e l(-Oo13 3 SR FORM (Golden Rod)