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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />RESTAURANT <br />FACILITY ID # <br />Z & 2- C-- <br />SERVICE REQUEST # <br />PLAN-GIEC—K <br />OWNER! OPERATOR <br />TIM LAM CHECK if BILLING ADDRESS <br />FACILITY NAME <br />HUONG LAN SANDWICHES <br />SITE ADDRESS <br />7555 Street Number Direction <br />CI PACIFIC AVE.,STE 155 <br />Street Name <br />STOCKTON <br />City <br />CALIFORNIA <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />6922 Street Number MITCHLEN CsTreet Name <br />Crry STATE ZIP <br />SLOUGHHOUSE CA. 95683 <br />PHONE #1 EXT. <br />( 916) 838 7389 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR KEVIN FONG CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />KEVIN FONG DESIGN <br />PHONE # <br />(r/k ) 6 c 7— ir'C ' <br />EXT. <br />HOME or or MAILING ADDRESS <br />2 STILL SHORE COURT <br />FAX # <br />( ) <br />Crry <br />SACRAMENTO <br />STATE <br />CA. <br />ZIP 95831 <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 nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 1:1 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGEN r DESIGNER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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: R-e-Witrti , VVLSL,Ir r\e,c;.4-,ciret,..... <br /> <br />CEV IV <br />COMMENTS: 0112—e i'VCY1. c tt__ 4.1^-' rv:( +6\ ( i ot 'A_ • - 0 k t lit_-'- AtiR n <br />1 4R u 3 2023 SAN ja4 <br />1.i.E.niViii,80 IN co ALTH 0 Niki NF UNT, <br />EPAI fi. 771;74 L <br />Ern <br />ACCEPTED BY: Cetv-i-t4 e ..sc 0 EMPLOYEE #: DATE: .5 _ ., ... 2, <br />ASSIGNED TO: Bel ...e. 0_ EMPLOYEE #: DATE: 5 .3 _ •,._.-. <br />Date Service Completed (if already Completed): SERVICE CODE: ss-2_.-5 ID I E: itipOi <br />Fee Amount: 1-(4, , Li-,...0 Amount PakitP4‘y.°0 Payment Date 3/3/2.3 <br />Payment Type V; Invoice # Check # /50.2 Received By: /1/1)---- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />?)2, o I oi <br />DATE: 1/24/2023