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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Restaurant BUSINESS NAME PC Construction Inc FACILITY ID # �� —� SERVICE REQUEST # SiZ ��V�ON OWNER/ OPERATOR Tea Amo, Contact: Tan Nguyen1 t CHECK if BILLING ADDRESS �P.Q !tat 14LQ �Ou-�ao�{, FACILITY NAME Tea Amo DATE: SITE ADDRESS 536 Street Number N I Direction EMPLOYEE #: Main St Street Name Manteca city 95336 ZI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Erzr' ( 714) 487-2360 APN # LAND USE APPLICATION # PHONE #2 EXT' ( ) Check # G�. ��Z(�t1LZ BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Steve Chau If�,(��( J CHECK If BILLING ADDRESS / BUSINESS NAME PC Construction Inc PHONE# EXr. HOME Or MAILING ADDRESS 2675 Kalamer Way FAx lr CITY Sacramento STATE CA ZIP 95835 BILLING ACKNOWLEDGEMENT: I, 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, STA nd FEDERAL laws. APPLICANT'S SIGNATURE: _ _ DATE: 3/25/2022 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® I,fAPPLICANT 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 th qlp .me it is provided to me or my representative. TYPE OF SERVICE REQUESTED: e ..Ji P. t �COMMENTS: �y3e'.Oymt,e, �aw S M V Vic/ �, �, S Fv,10 IN ?? H�CCOUN Ty pEPARTMENr ACCEPTED BY: vwvi EMPLOYEE #: DATE: ASSIGNED TO: Fa v ift V EMPLOYEE #: DATE: Date Service Completed (if ilready completed): SERVICE CODE: ri PIE: / Fee Amount. 17e,�;& DD Amount Pa �b Payment' Date 3 f ZZ Payment Type l_JC Invoice # Check # G�. ��Z(�t1LZ Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003