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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 />SERVICE REQUEST # <br />BUSINESS NAME Ournl Sushi @ Sprouts #464 <br />PHONE # E%T. <br />511� 0®3VLOR <br />Food Establishment <br />704-926-2200 <br />HOME or MAILING ADDRESS 11949 Steele Creek Rd. <br />OWNER/ OPERATOR <br />Lwin Family CO, LLC DBA Oumi Sushi <br />CHECK if BILLING ADDRESS <br />FACILITYNAME Oumi Sushi @ Sprouts #464 <br />STATE NC ZIP 26273 <br />SITE ADDRESS <br />Pacific Ave Suite 1040 <br />EMPLOYEE #: <br />Stockton <br />95207 <br />5308 Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1S� <br />Payment Date <br />11949Steele <br />Payment Type <br />Creek Rd. <br />S[reat Number <br />Received By: <br />SVoet Name <br />CITY <br />STATE ZIP <br />Charlotte <br />NC 28273 <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />( 704 ) -926-2200 <br />PHONE #2 Ex . <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Kritika Shakya <br />CHECK If BILLING ADDRESSIL.I <br />BUSINESS NAME Ournl Sushi @ Sprouts #464 <br />PHONE # E%T. <br />704-926-2200 <br />HOME or MAILING ADDRESS 11949 Steele Creek Rd. <br />FAx# <br />( )704-926-2201 <br />Cir Charlotte <br />STATE NC ZIP 26273 <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 ±6 " DATES: /1 /24/2023 <br />PROPERTY/ BUSYNESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT q( Food SAfety & Compliance Manager <br />IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentakite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tF a it is <br />provided to me or my representative. RC. <br />TYPE OF SERVICE REQUESTED: <br />Q <br />COMMENTS: <br />� HR HM�COON3 <br />@pqR ��Nj3' <br />ACCEPTED BY: =EMPLOYEE <br />#: C1 z <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Comp ed (if already completed): <br />SERVICE CODE:0(01 <br />PIE: / 6 <br />V <br />Fee Amount: 15coAmount <br />Paid <br />1S� <br />Payment Date <br />Z13 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 0&hfirrfiA f o -n i�-- 1S(ob gT SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />