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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Boba milk tea <br />FACILITY ID if ,—. ‘. ''(1 <br />-s)C/ <br />SERVICE REQUEST <br />'C'C) <br />if <br />- <br />OWNER / OPERATOR <br />CHECK if Thien Vi Ngo BILLING ADDRESS <br />FACILITY NAME <br />Tea 86 <br />SITE ADDRESS <br />8034 Street Number Direction <br />El Dorado ST, Suite 6 <br />Street Name <br />Stockton <br />City <br />95210 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />2729 Street Number <br />Pine Brook DR <br />Street Name <br />CITY STATE ZIP <br />Stockton CA 95212 <br />PHONE #1 Ext. <br />( 209 ) 242-1868 <br />APN # LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Thien VI Ngo CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Tea 86 <br />PHONE # <br />( 209 ) <br />En. <br />242-1868 <br />HOME or MAILING ADDRESS <br />2729 Pine Brook DR <br />FAx # <br />( ) <br />CITY <br />Stockton <br />STATE <br />CA <br />ZIP <br />95212 <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, / STAT and FEDERAL laws. <br />7;ftw <br />PROPERTY / BUSINESS OWNER IX OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 Business Owner <br /> <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />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' yt n time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />D 1DU: <br />COMMENTS: 9 2022 AUG 2 <br />: JOA:: SAN <br />, _ENVIRONME TY 1-1,4\1-THDEp AR TMENT <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 i DATE: 8-29-22 <br />ASSIGNED TO: Stephanie Ramirez EMPLOYEE #: 1084 DATE: 8-29-22 <br />Date Service Completed (if already completed): SERVICE COOE: 523 PIE: 1601 <br />Fee Amount: 468 - Amount Paid 4 t zii_6g, 6 0 Payment Date 2-A-2— <br />Payment Type Se-1 Invoice # Check # 14(-0e 7 3 ,../-1 I Received By: zA--- <br />APPLICANT'S SIGNATURE: DATE: 08/25/2022 <br /> <br />END 48-02-025 payment 149093491 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003