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DocuSign Envelope ID:2CB7CO61-6B16-4B72-9B3B-D9C6EF659CDD <br /> JAN JOAQUIN t-(-)UN I Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Chinese Restaurant r112-10 1 "�9-10?)(6 o4 <br /> OWNER/OPERATOR Xiuhong Ma / Hong and Bo LLC CHECK if BILLING ADDRESS❑x <br /> FACILITY NAME New Shanghai Restaurant <br /> SITE ADDRESS 6041 Pacific Ave Stockton 95207 <br /> Street Number Direction Street Name City ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6038 Saxton CT <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95212 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 408) 838-6612 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 T11"I'tf.DERAL laws. <br /> 5/24/2023 <br /> APPLICANT'S SIGNATURE: "E0A8FMA42TC3A04t9CX. DATE: <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAPPLICANT 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 tbAame time it is <br /> provided to me or my representative. //��'' YY <br /> TYPE OF SERVICE REQUESTED: Change the ownership of the restaurant. AE/V <br /> COMMENTS: <br /> S4 IV Jo,g y 26 2023 <br /> N�ACTH D MRNO��TY <br /> T MFNT <br /> ACCEPTED BY: f✓tet e C-D EMPLOYEE#: DATE: -5-7! ,_'Z3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: LIQ <br /> Date Service Completed (if already completed): SERVICE CODE: L-2( <br /> Fee Amount: 5 -- Amount Pai K/- Payment Date 23 <br /> Payment Type ; Invoice# Check# k'Z(473,7�K Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />