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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 1 FACILITY ID# SERVICE REQUEST# <br /> Restaurant OD Lqn4S <br /> OWNER/OPERATOR <br /> Ranjeet Singh CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> TOGO'S MANTECA PC#332597 <br /> SITE ADDRESS S Main St Manteca 95337 <br /> 1115 Street Number I Direction I Street Name city zip Catle <br /> HOME or MAILING ADDRESS (If Different from Site Address) Cynthia Ct <br /> 3115 Street Number Street Name <br /> CITY STATEzipZIP 95377 <br /> Tracy <br /> PHONE#1 Ea. APN# LAND USE APPLICATION# <br /> ( 209 ) 5794014 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR <br /> Ranjeet Singh CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Ezi' <br /> TOGO'S MANTECA PC#332597 <br /> HOME or MAILING ADDRESS FAX# <br /> 3115 Cynthia Ct ( ) <br /> CITY Tracy STATE CA zip 95377 <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: RA,sU'e.ef-s*& DATE: 05-25-2022 <br /> PROPERTY/BusiNESs OWNER® OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br /> IfAPPLiCANT 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 o£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 andyt,thee same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MAY 1 7 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT. <br /> wumt, or (,�y ! jVli <br /> ACCEPTED BY: o EMPLOYEE#: ,y DATE: Z`7 ZZ <br /> ASSIGNED TO: V o EMPLOYEE#: y� g DATE: ^) / Z,Z <br /> Date Service Completed (if already co Pleted): SERVICE CODE: IXPI P 1 :4 <br /> Fee Amount: s"Z Amount Paid I S Z Payment Date � �2XJ 2Z <br /> Payment TypeC Invoice# ,,rk S '+ Received By: <br /> EHD 46-02-025 SR M(Golden Rod) <br /> REVISED 11/17/2003 <br />