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SAN JOAQUIN COUNTY ENVIRONN'IENTAL Ii EALTH DEPARTMENT <br />SERVICE REOUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST# <br />PHONE# Fir. <br />Eleven Ten Architects <br />Lil <br />408 5053805 <br />Restaurant <br />DATE: <br />FAx# <br />480 Boynton Ave, Unit 5 <br />OWNER I OPERATOR <br />( <br />CHECK If Blulnc AOOREss <br />Sandesp Sharda and Sanjeev K. Shards <br />f�0 V <br />FACILITY NAME Doaba Sweats and Restaurant <br />Payment Date 2fl <br />Payment Type <br />SITE ADDRESSN <br />Invoice# Check# a <br />Received By: <br />Tracy Blvd <br />3310 Street Number <br />Dlre[Ilon <br />Stmol Name <br />CI <br />Zia Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1476Calumbine wa <br />a4eel Number <br />Sneet Name <br />CITY <br />STATE ZIP <br />Lrvmmom <br />,A 94551 <br />PNONE#1 E, <br />APNit <br />LAND USE APPLICATION# <br />( 408 ) 2040110 <br />PNONE#2 Est. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE R EQUESTOR <br />REOUESTOR 1 <br />SLIDOD Lhll <br />CHECK If BILLING AOp0.Ea5 <br />BUSINESS NAME <br />PHONE# Fir. <br />Eleven Ten Architects <br />Lil <br />408 5053805 <br />HOME or MAILING ADDRESS <br />DATE: <br />FAx# <br />480 Boynton Ave, Unit 5 <br />( <br />QTY San Jose <br />STATE CA ZIP 95117 <br />BILLING ACKNOWLEDGENIENT: 1. tho undersigned property or business owner, operator or authorized agent of same. <br />acknrnvledge that til site and/o ro ct specific ENVIRONa I Al. HE,u: rt DI. PAR R\[[%NI hourly charges associated w W1 duS project <br />or aclicit) trill be billed tom or my husiness Ils idcnbfted on thus form. <br />I also certify that I wave prepare his application and 1110 T rk to be performed will be done in accordance tsjih all SAN JOA01AN <br />CUL\Tl- Ordinance (,urlr.r, S'tondm ,—�ST Irid FERE - _laws. <br />2 <br />o <br />6 �2ei <br />APPLICANT'S SIGNATURE: DATE: <br />1'aorrarn/BosTrvrss Osu¢a� OPEIIUT014 f MANAeeR❑ OnulNArnunuzo:u Ma: El <br />!l-dPP[fC4h7 is not the 131117NG RIRn'proofrfallluiri;.urinu rn sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geoteduucal data and/or enmionmenuII&Ld assessment <br />infomlatiou to OIC S:W JOAQI IIN COI RTl E>CIRO\NIENI': IL HFAL'nI DI'.PAItPMhNI CIS SO0n aS it S available andel thesail time it is <br />provided to me or nq representalicc � A I., <br />TYPE OF SERVICE REQUESTED: <br />Plan Re1'icw <br />COM14ENTS: Tease=_rcaii plan leviary commmrls to Simon Lin@ stmDri0�T I I l0arcmlect com <br />--PC t) fiC. <br />ACCEPTED BY: <br />/ L'," �- _ <br />EMPLOYEE#:DATE: <br />AssIGNED TO: <br />Lil <br />EMPLOYEE#: <br />DATE: <br />Date Service <br />orrpleted (if already completed): <br />SERVICECODE: 5; _-5, <br />PIE: <br />Fee Amo <br />f�0 V <br />Amount P O74L �� <br />Payment Date 2fl <br />Payment Type <br />Invoice# Check# a <br />Received By: <br />;I- <br />148-02-025 <br />EHD48-02025 Z� 9 /�O SR FORM (Golden Rod) <br />REVISED 11117i2003 - <br />