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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Restaurant <br />FACILITY ID #:Woripe5i <br />�/� � �/ <br />ERVICE REQUEST # <br />(✓6 <br />OWNER / OPERATOR <br />Sony Singh <br />CHECK If BILLING ADDRESS <br />FAc1UTY NAME Sourdough & Company <br />ACCEPTED BY: <br />SITE ADDRESS 2126 <br />Street Number <br />I Direction <br />Daniels Street <br />I Street Name <br />ASSIGNED TO: <br />Manteca <br />city <br />95337 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />DATE: so `L ) <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Exr. <br />`/N'� <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ' ,t / � r <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />K & U Construction Inc <br />COMMENTS: <br />PHONE #, , Ex. <br />7. qab ZO <br />HOME or MAILING ADDRESS 3204 Sparrow Drive <br />ACCEPTED BY: <br />FAX # ) i� <br />CITY Sacramento <br />STATE CA ZIP 95834 <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 1 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 an FED laws. <br />APPLICANT'S SIGNATURE: DATE: 06/29/2021 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTO Operator's Rep <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tule <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 environmentaUsite 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: <br />COMMENTS: <br />�0 <br />h�ryoF�Hopp�11 <br />ACCEPTED BY: <br />EMPLOYEE #: �j Z- <br />DATE: 30 <br />ASSIGNED TO: <br />EMPLOYEE#: �q 0 <br />DATE: so `L ) <br />Date Service Compleiticiqlf already completed): <br />SERVICE CODE: 6� <br />P / E: ( 6 0 <br />Fee Amount: <br />Amount Pal !) <br />Payment Date <br />1 <br />Payment Type <br />Invoice # <br />Check # 12 �3S <br />Rece ed By: <br />EHD 48-02-025 <br />(` �� �� (� t v� SR FORM (Golden Rod) <br />REVISED 127/2003 <br />