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r , <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail SRQ�Q�8�33 <br /> OWNER/OPERATOR <br /> Asiana Cuisine Enterprises, Inc CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ace Sushi @Save Mart 39 <br /> SITE ADDRESS <br /> 4725 Quail Lakes Dr. Stockton F95207 <br /> Street Number Direction Street Name City Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 22771 S.Western Ave. <br /> Street Number Street Name <br /> CITY Torrance STAT IbA <br /> ZIP 90501 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (310 )327-2223 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( 310 ) 730-5440 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Daniel Amspaugh <br /> BUSINESS NAME PHONE# EXT. <br /> 310 730-5440 <br /> HOME or MAILING ADDRESS FAX# <br /> 22771 S. Western ave ( 310 ) 327-9256 <br /> CITY Torrance STATE CA ZIP 90501 <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 1 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 /> TA� <br /> APPLICANT'S SIGNATURE: I' `` L�4 DATE: 10/12/23 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER, GE ❑ OTHER ALITHORIZED AGENT iP Operations <br /> if APPLICANT 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 a[)d me time it is <br /> provided to me or my representative. PAY M E N <br /> TYPE OF SERVICE REQUESTED: CccKtC <br /> �K <br /> COMMENTS: NOV 01 2023 <br /> / SANENVIRONMENTAL <br /> JOAQUIN COUNTY��HEALTH DEPARTMENT <br /> ACCEPTED BY: �f� �'c, .ti EMPLOYEE#: DATE: IV. iU 2 <br /> ASSIGNED TO: Q_ EMPLOYEE#: DATE: I0 • 7G L <br /> Date Service Completed (if already completed): SERVICE CODE: ��^t / PIE: t G}L <br /> Fee Amount: iD Amount Paid a Payment Date <br /> Payment TypeInvoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />