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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ---7:1FACILITY ID# �/�SERVICE REQUEST# <br /> Karin knorr Aoy 51�� <br /> OWNER/OPERATOR Benny Lin CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Ramen 101 Restaurant <br /> SITE ADDRESS11 21 Daniels street Manteca Ca 95337 <br /> 2/ r Z/ Street Number Ofrection Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3878 Fallon Rd Street Number Street Name <br /> CITY Dublin STATE Ca ZIP 94568 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( 610 239-6480 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR G/t!s/ /7 S /� /� � CCIL— , <br /> Wanping Deng UO ( (Q CHECK If BILLING ADDRESS <br /> BUSINESS NAMPHONE# Ex. <br /> EFW Designers 510-366-6727 <br /> HOME or MAILING ADDRESS FAX# <br /> 39210 State St Suite 119 1 ( ) <br /> CITY Fremont STATE Ca ZIP 94538 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONwNTAL 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 <br /> ��FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �I' R r b V D DATE: Apr 13,2022 <br /> PROPERTY/BUSWESs OWNER❑ O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Designer <br /> IrAPPLICANT 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 same time it is <br /> provided to me or my representative. �q <br /> TYPE OF SERVICE REQUESTED: l? •• <br /> COMMENTS: <br /> APR <br /> Please email to:TW_design511 @yahoo.com if have any information $AN <br /> E O'9ly <br /> Or questions, �� (LA �5 IV1 �� �RI� EMe <br /> H<���4UIMEN1y <br /> ACCEPTED BY: / 1�C�(,:6 EMPLOYEE#: DATE: <br /> ASSIGNEDTO: v EMPLOYEE#: DATE: _ C <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P I E: <br /> Fee Amount: %1 <br /> Amount Paid Payment Date I 122 <br /> Payment Type v1 Invoice# ck ; I2Cggj LV4' Received By: w 717r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />