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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # COMMENTS: SERVICE REQUEST # Grocery Market electronic FAx# CITY Stockton S O OWNER / OPERATOR Phillip Nguyen CHECK If BILLING ADDRESS El FACILITY NAME Manila Express HEg ,PA SITE ADDRESS 1108E Hammer Lane Stockton 95205 Street Num bar Direction Street Name DATE: 3-3-22 city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 3913 Date Service Completed (If already Completed): Spyglass CT SERVICE CODE: 523 Street Number PIE: 1601 Street Name CITY Stockton q-6, Q li STATE CA. ZIP 95210 PHONE #1 Ext' Payment Type ` f APN # LAND USE APPLICATION # (209) 478-2986 Received By: 09403011 PHONE #2 En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Steven Torres, Architect CHECK if BILLING ADDRESS BUSINESS NAME Apex Architecture COMMENTS: PHONE # Ext' 662-4874 HOME or MAILING ADDRESS 735 S. Shasta Ave electronic FAx# CITY Stockton STATE CA ZIP 95205 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: / 4� N�2cc�+L DATE: 1-25-2022 PROPERTY/ BUSINESS OWNER® OPERATOR /MANA ER❑ OTHER AUTHORIZED AGENT 11 If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at jk1eR5�me time It Is provided to me or my representative. pr. _ MSA/, TYPE OF SERVICE REQUESTED: plan check V COMMENTS: R electronic 03 pp??SqN�ZLHFpAL HEg ,PA T ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 3-3-22 AsSIGNEDTO: Darla Afonskala EMPLOYEE#: 9825 DATE: 3-3-22 Date Service Completed (If already Completed): SERVICE CODE: 523 PIE: 1601 Fee Amount: 456 Amount Paid q-6, Q li Payment Date 3 2.2_ Payment Type ` f Invoice # Check # /3 g � 7 Received By: EHD 48-02-025 Payment # 139878637 REVISED 11/17/2003 VrGI4Z31iv SR FORM (Golden Rod)