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Pao <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail 594=8--'t 315 <br /> OWNER/OPERATOR <br /> Asiana Cuisine Enterprises, Inc CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ace Sushi @Save Mart 781 <br /> SITE ADDRESS South Tracy B;vd Trac 95376 <br /> 875 Street Number Direction Street Name y City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 22771S.Western Ave. <br /> Stree[Number Street Name <br /> CITY STATE ZIP <br /> Torrance CA 90501 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (310 )327-2223 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 310 )730-5440 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Daniel Amspaugh CHECK If BILLING ADDRESS <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 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: L',.4 DATE: <br /> 10/12/23 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTX1 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S` <br /> COMMENTS: <br /> NOV 01 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> !? -3 a X23 <br /> ASSIGNED TO: �—n Va^Q� EMPLOYEE#: DATE: !V 7 G r 23 <br /> Date Service Completed (if already completed): SERVICE CODE: D/ / P : <br /> Fee Amount: G Amount Paid i Payment Date <br /> Payment Type Invoice# Check# '3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> h6 REVISED 11/17/2003 <br />