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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> (SERVICE REQUEST# <br /> Restaurant �qq p' <br /> � D <br /> OWNER/OPERATOR <br /> Anton Nguyen CHECK If BILLING ADDRESS <br /> FACILITY NAME Ono Hawaiian BBQ <br /> SITE ADDRESS —F <br /> 190 c 1 <br /> Commerce Ave. J U Manteca 95336 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 21700 Copley Dr. <br /> CITY <br /> Street Number Street Name Diamond Bar STATE ZIP <br /> CA 91765 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( ) 909.594.3388 EXT.142 <br /> [PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TBD <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE zip <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 SIGNATURE: Pamela Ord DATE: 12.10.2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Project Manager <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: N�2,.J.J s c 'j <br /> COMMENTS: �Z Jit /`! <br /> ACCEPTED BY: r i,en���.t C"' EMPLOYEE#: DATE: <br /> ASSIGNED TO: W V t� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C P/ : <br /> Fee Amount: S' Amount Paid `-tis Payment Date 1Z 13 1sg U/ <br /> Payment Type Invoice# Check# (CR U Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />