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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 7-� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Food SRWB-il 5 2. <br /> OWNER/OPERATOR <br /> Sai Pan CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Beard Papa's <br /> SITE ADDRESS 118W 10TH STREET, UNIT B TRACY 95376 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3104 TACOMA DR <br /> Street Number Street Name <br /> CITY LATHROP STATE CA ZIP 95330 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (415) 964-8816 <br /> PHONE#2 Eur. EMAIL winniewenw@gmail.com BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Sai Pan <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Pantastic LLC PHONE# EXT. <br /> 415)964-8816 <br /> HOME or MAILING ADDRESS 3104 Tacoma Dr FAx# <br /> ( ) <br /> CITY Lathrop STATE CA ZIP 95330 EMAIL wlnnlewenw@gmall.com <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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: /� DATE: 02/22/2024 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prodded to me or my <br /> representative. 4 Y <br /> TYPE OF SERVICE REQUESTED: Chp�1 <br /> COMMENTS: <br /> sAN',04 Qtj <br /> V/R ?D?4 <br /> NEND M ��NrYqTpANRr7e <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 —'2-2— 2 y <br /> ASSIGNED TO: 1^rn��,�� EMPLOYEE#: DATE: '2 <br /> Date Service Completed (if already completed): SERVICE CODE: C) L J PIE: �o©Z <br /> Fee Amount: �2 Amount Paid � Payment Date L - 2 Z- 2— <br /> Payment <br /> Payment Type C C Invoice# Check# 176 FID A,7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />