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Reed/L f7 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST rg. 5'4 <br />Type of Business or Property <br />Retail <br />FACILITY ID # <br />Revj <br />SERVICE REQUEST # <br />512o508-3-3-4-m <br />OWNER! OPERATOR <br />CHECK if <br />Asiana Cuisine Enterprises, Inc <br />BILLING ADDRESS <br />FACILITY NAME <br />Ace Sushi @Save Mart 94 <br />SITE ADDRESS <br />15240 Street Number <br />South <br />Direction <br />Harlan Rd <br />Street Name <br />Lathrop <br />City <br />95330 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />22771 Street Number <br />S. Western Ave. <br />Street Name <br />CITY STATE ZIP 90501 Torrance CA <br />PHONE #1 Err. <br />(310 )327-2223 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />310 )730-5440 - <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Daniel Amspaugh CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Ace Sushi <br />PHONE # <br />010 )730-5440 <br />EXT. <br />HOME or MAILING ADDRESS <br />22771 S. Western Ave <br />FAX # <br />(310 ) 327-9256 <br />Ow Torrance CA STATE 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: <br />PROPERTY! BUSINESS OWNER OPERATOR / MANCAdER 0 OTHER AUTHORIZED AGENT El 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: (E.'1.4.c-)Lk 14,-1----r. <br />I r-t it iwii...1. • <br />RECEIVED <br />COMMENTS: <br />NOV 0 1 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: CO( f ..A-LCI IA) EMPLOYEE #: DATE: 2,0 "" 2-3 <br />ASSIGNED TO: 1,1-SA. /A-01,AL•fr" EMPLOYEE #: DATE: t 0 .-90 ._....) <br />Date Service Completed (if already completed): SERVICE CODE: (..) ( ,PIE: 166 2.- <br />Fee Amount: <br />i 4 vZ <br />Amount Paid 2 k -2 — Payment Date b 1 / <br />Payment Type <br />ry <br />,L Invoice # Check # 3 6 s-v Received By: itii-e.7 4 <br />DATE: 10/12/23 <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003