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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 �} 123 SK 00;iio � kv 0 <br /> OWNER/OPERATOR Mutajarin Niyamosot CHECK If BILLING ADDRESS <br /> FACILITY NAME Golden Spoon <br /> SITE ADDRESS 439 N main st Manteca 95336 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 601 Larkin St Street Number Street Name <br /> CITY San Francisco STATE California ZIP 94109 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (415)425-6739 <br /> PHONE#2 E><T. BOS DISTRICT LOCATION CODE <br /> (659l246-9356 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �i/l. t I <br /> YiAk K. CHECK if BILLING ADDRESS <br /> BUSINESS NAME ..7da PHONE# Exr. <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 FEI <br /> DERAL iiwS. <br /> APPLICANT'S SIGNATURE: ,O(fN DATE: 12/20/2022 <br /> PROPERTY/BUSINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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/Gae time it is <br /> provided to me or my representative. /`�^y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: IV <br /> NFgL���/NCoO?? <br /> r7 yOFp' ��y�y <br /> ACCEPTED BY: EMPLOYEE#: n� S DATE: l 2 2(7 n 2. <br /> ASSIGNED TO: �� EMPLOYEE#: X��� DATE: /'Z fL/ <br /> Date Service Completed (if already completed): SERVICE CODE: I !PIE: 0 2 <br /> Fee Amount: ` Amount Pai N(rPayment Date <br /> Payment Type i5� Invoice# Check# /,S ' 773? 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />