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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BOBA and DESSERT DRINKS ._ FACILITY ID # (\ et SERVICE REQUEST # SQ002' 0 I 2-3 OWNER/OPERATOR CHECK if MICHAEL AND LALIE CUISON BILLING ADDRESS FACILITY NAME BAMBU DESSERTS & DRINKS SITE ADDRESS 1865 Street Number W Direction ELEVENTH STREET E04 Street Name TRACY City 95376 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 778 Street Number NORTH QUESTA COURT Street Name CITY STATE ZIP MOUNTAIN HOUSE CA 95391 PHONE #1 EXT. ( 925 )428-7008 APN # LAND USE APPLICATION # PHONE #2 EXT. ( 925 )428-7101 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR MICHAEL CUISON CHECK if BILLING ADDRESS EY BUSINESS NAME M&L and Sons LLC PHONE # ( 925 ) 428-7008 EXT HOME Or MAILING ADDRESS 778 NORTH QUESTA COURT FAX # ( ) CITY MOUNTAIN HOUSE STATE CA ZIP 95391 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applicatio a th e work to be performed will be done in accordance with all SAN JOAQUIN - laws. COUNTY Ordinance Codes, Standards, STATE APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER ID/ OPERATOR / MANAGER 0 DATE: 12/06/2022 OTHER AUTHORIZED AGENT 0 f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ Ret essment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as it is available and Etyne it is provided to me or my representative. TYPE OF SERVICE REQUESTED: L DEC 0 i ULL COMMENTS: ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 12-6-22 ASSIGNED TO: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 12-6-22 Date Service Completed (if already completed): SERVICE Com: 523 PIE: 1601 Fee Amount: 468 Amount Paid I) 1/6 %. Payment Date 1 2,./ --/..1 2,t2 2._ 2, Payment Type v 1 4_, R- Invoice # Check # Received By: Eli payment 153857375 12/ Co/1,o SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003