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NLo 1 /4-k LD4, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Small Takeout Bakery <br />FACILITY ID <br />9, 0'291 <br /># SERVICE REQUEST # <br />3e.00g(351--1 <br />OWNER / OPERATOR <br />CHECK if <br />Matin Habibi <br />BILLING ADDRESS <br />FACILITY NAME <br />Taaza Naan <br />SITE ADDRESS 2213 <br />Street Number Direction <br />Tracy Boulevard <br />Street Name <br />Tracy <br />City <br />95376 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CrrY STATE CA ZIP <br />PHONE #1 EXT. <br />( 209 ) 594-3941 <br />APN # <br />23207005 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Stacey Wellnitz <br />CHECK if BILLING ADDRESS La" <br />BUSINESS NAME <br />Commercial Arch <br />PHONE # <br />( 209 ) 571-8158 <br />EXT. <br />HOME or MAILING ADDRESS <br />616 14th Street <br />FAX # <br />( ) <br />Ci-ry <br />Modesto <br />STATE <br />CA <br />ZIP <br />95354 <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: February 3, 2023 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 3 <br /> <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 time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:k\..\ 4.. t‘-L_ Le-'1-ti --r- .0 f? eeriLl 4 r <br />COMMENTS: <br />A <br />.e c-txyytt.c._.‘ <br />Lipp, <br />Ft9 0 ,, <br />sALvja4 0 2023 <br />te4C\PROevCOU H DEprN 7-4 LN ry <br />R 7-4,74 r <br />ACCEPTED ACCEPTED BY: ( ct V-6.4 C C C 25 EMPLOYEE #: DATE: 2_ ..._ •'- -— <br />ASSIGNED TO: 1........_ V.,se s EMPLOYEE #: DATE: 2_ .--3 ,_ 2.3 <br />Date Service Completed (if already completed): SERVICE CODE: 5 1.;2., P I E: 1 . , <br />Fee Amount: ift0C6- ,e700 Amount Paid0 i/6„g (y*-) Payment Date <br />Payment Type VI-- Invoice # Check # /-6 ..,:7 7 c,23— Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003