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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Kritika Shakya <br />REQUEST # <br />Food Establishment <br />new <br />PHONE # Ex . <br />cSERVIICE <br />"Q Nw ZS <br />OWNER / OPERATOR <br />704-926-2200 <br />Lwin Family CO, LLC DBA Oumi Sushi <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Oumi Sushi @ Sprouts #466 <br />SITE ADDRESS <br />( 1704-926-2201 <br />Golden Valley Pkwy <br />I <br />STATE NC ZIP 28273 <br />Lathrop <br />95330 <br />16576 Street Number <br />Direction <br />Street Name <br />SERVICE CODE: O1� 1 <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I Amount Paid )IS �n <br />Payment Date <br />11949 <br />Steele <br />Greek Rd. <br />Street Number <br />Received By: <br />Au— <br />Street Name <br />CITY <br />STATE ZIP <br />Charlotte <br />NC 28273 <br />PHONE#t ExT. <br />APN# <br />LAND USE APPLICATION# <br />( 704) -926-2200 <br />PHONE #2 En. <br />( ) <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Kritika Shakya <br />CHECK If BILLING ADDRESSO <br />BUSINESS NAME Ouml Sushi @ Sprouts #466 <br />ED <br />PHONE # Ex . <br />JAN 11 2023 <br />704-926-2200 <br />HOME Or MAILING ADDRESS 11949 Steele Creek Rd. <br />SAN JOAQUIN COUNTY <br />eNVIRONMENTAL <br />FAX# <br />NEALTN QEPARTMENT <br />( 1704-926-2201 <br />CITY Charlotte <br />STATE NC ZIP 28273 <br />BILLING ACKNOWLEDGEMENT: I, 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: A Q4* DATE: 1/10/2023 <br />PROPERTY/BOSINEss OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ER/FoodSAfety&ComplianceManager <br />!f 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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />I�AYM <br />COMMENTS: <br />ED <br />JAN 11 2023 <br />SAN JOAQUIN COUNTY <br />eNVIRONMENTAL <br />NEALTN QEPARTMENT <br />ACCEPTED BY: -� ^ Yr \,„ /� =EMPLOYEE <br />t "V� `C7\ <br />#: \4S <br />DATE: 1 —111 — 237 <br />11 <br />ASSIGNED TO: <br />EMPLOYEE #: q S� <br />DATE: <br />— 11 — 7-2> <br />Date Service Completed (if already completed): <br />SERVICE CODE: O1� 1 <br />P I E. <br />FeeAmourdl <br />I Amount Paid )IS �n <br />Payment Date <br />t— ' l — 2 3 <br />Payment Type cc <br />Invoice # <br />Check # <br />Received By: <br />Au— <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rad) <br />I <br />WA <br />