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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 �A b � 06 U�(j7 <br /> OWNER/OPERATOR <br /> Harr}'Yu CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Midori Fine Asian Cuisine <br /> SITE ADDRESS <br /> 2541 INaglee Road Tracy 95304 <br /> Street Number I Direction Street Name I city I Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Rocky Harbor Road <br /> X5971 Street Number t Narne <br /> CITY l athrop STATE ZIP <br /> CA 95330 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (2o9 ) 981-9981 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Guo Yu CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME New Greatwall Builder PHONE# EXT. <br /> 916 6o1- 07 <br /> HOME or MAILING ADDRESS FAX# <br /> 7017 L}•zldale Cir ( ) <br /> CITY Elk Grove STATE CA ZIP 95758 <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 JoAQufN <br /> COUNTY Ordinance Codes,Standards,STATE andFEDERAL laws. <br /> APPLICANT'S SIGNATURE: J tzll 1 DATE: tx) <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPLICANT is not the BILLING PARTY,wYof of authorization to 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, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ale time it is <br /> provided to me or my representative. r 41 <br /> TYPE OF SERVICE REQUESTED: �® <br /> COMMENTS: <br /> 2 g 2n!,g <br /> SAN J0AQ(IrN C <br /> HEALTH0�PVWTALTy <br /> NT <br /> ACCEPTED BY: /�r�Q/JIn 1"7 EMPLOYEE#: DATE: r 9 <br /> ASSIGNED TO: �C , EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: [ /� <br /> Fee Amount: U� Amount Paid �� Payment Date / G <br /> Payment Types Invoice# Check# Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 IV <br />