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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Tea and coffee shop FA uo253 to 5 S�Oog 'POL-f <br /> OWNER/OPERATOR <br /> Duy Phung CHECK If BILLING ADDRESS <br /> FACILITY NAME Rose Tea Lounge Stockton <br /> SITE ADDRESS 5634 N Pershing Ave Stockton 95207 <br /> Street Number I Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9160 E Stockton Blvd, STE 120 <br /> Street Number Street Name <br /> CITY Elk Grove ENE ZIP <br /> ENE 95FS24 <br /> PHONE#; 916 9930999 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Duy Phung CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Rose Tea Lounge PHONE# EXT. <br /> 916 9930999 <br /> HOME Or MAILING ADDRESS 35 Oliver Ct Q FAX# <br /> CITY Elk Grove STATE CA ZIP 95758 <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRow-ENTAL HEAL:rH DEPART4fEN'r hourly charges associated with this project <br /> or activity Twill be billed to Ise or my business asidentified 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 Cortes,Standards,ST,.\TT and FEDERAL laTr-s. <br /> APPLICANT'S SIGNATURE: 41 DATE: 04/12/2023 <br /> PROPERTY/BUSINESS OWNER& OPERATOR/MANAGER ❑ OTHER ALTHORtzED AGENT❑ <br /> If APPLICANT is not the Bn:ttmG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, L 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 LO 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 SEP-vtcF R.EQuESTEA: Vv <br /> COMMENTS: <br /> ACCEPTED BY: CaL V-.-,A< S Gc7 EMPLOYEE M DATE: L—2 Z <br /> ASSIGNED TO: �� f�r� EMPLOYEE#: DATE: G� <br /> bate Service VDIT(pieted t(r alreat ry completed'f. Butm t tvErt. Q 6 t I -i E. �p Q 2— <br /> Fee <br /> Fee Amount: I s(Q _ Amount Paid Payment Date <br /> Payment Type l Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />