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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> FIY)() 00 S1 008559 <br /> OWNER / OPERATOR <br /> Mandeep Dua CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME SuperStop <br /> SITE ADDRESS 290 N . Main St . Manteca 795336 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> (209) 239 -4475 <br /> PHONE #2 EXT* BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR ol <br /> REQUESTOR <br /> James Otto CHECK If BILLING ADDRESS <br /> BUSINESS NAME LC Services PHONE # EXT, <br /> 559 444 - 1730 <br /> HOME Or MAILING ADDRESS FAX # <br /> 3887 N Valentine Ave . ( ) <br /> CIT` Fresno STATE CA zIP 93722 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : lames Otto DATE : 9/6/2022 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project Coordinator <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : f T f yam ` RECEIVED <br /> COMMENTS : SEP <br /> yAN JOAQUIN COUNTY. <br /> ENVIR UEPARTMBNf <br /> HEALTH UE <br /> ACCEPTED BY: yf�7J� �J A EMPLOYEE # : DATE >� <br /> ASSIGNED TO : LZC.�-�Cr yc hJ EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed) : - SERVICE CODE: /eJ f, ati1/ O 7 P I E : en f <br /> Fee Amount: �Ozm — Amount Paid 0 �. Payment Date_/ a e2, 2,2, <br /> Payment Type Invoice # SD Received By : <br /> EHD 4&02-025 2,t, 2� SR FORM (Golden Rod) <br /> 07/17/08 <br />