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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 />lattf 5 '7 <br />SERVICE REQUEST # <br />SgaZ (6-1-ckct i <br />OWNER! OPERATOR <br />Bi ying liu CHECK if BILLING ADDRESS <br />FACILITY NAME K-Town <br />SITE ADDRESS 5420 <br />Street Number Direction <br />Pacific Ave <br />Street Name <br />Stockton <br />City <br />95297 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />9898 Street Number <br />Capeverde Dr <br />Street Name <br />CITY STATE ZIP <br />Elk Grove Ca 95757 <br />PHONE #1 Ext. <br />( ) 91 6 698-7661 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Evr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Chirs Chen CHECK if BILLING ADDRESS <br />BUSINESS NAME Chris Construction Inc PHONE # <br />( ) 916 832 8898 <br />EXT . <br />HOME or MAILING ADDRESS <br />8425 Tragus Way <br />FAX # <br />( ) <br />CITY Elk Grove STATE Ca ZIP 95624 <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: (i rsPili D DATE: Oct 31,2023 <br />PROPERTY / BUSINESS OWNERD OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT IS TW Designers <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, geoteclutical 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: Rie...„ vvt-o-rAsk- 4 peNk.Atikt.s., _c_ (--‘e %.. , ..,,_,J., A.ik.„, FAYMEN <br />COMMENTS: -(-yrn`tt, ca. 647149 RECEIVE <br />DEC 0 4 202 <br />SAN JOAQUIN COUP ENVIRONMENTAL HEALTH DEPARTME <br />ACCEPTED BY: Csx vme- tik e"3 c if <br />EMPLOYEE #: DATE: J.L.,_ 4 ,.._ 7,3 <br />ASSIGNED TO: -----?),,ke4," EMPLOYEE #: DATE: 12 A -1-3 <br />Date Service Completed (if already completed): SERVICE CODE: ,s .23 P / E: 1 (g 0 1 <br />Fee Amount: ..,ic,4510 ....--- Amount Paid S-47 — Payment Date I <br />Payment Type Vi 4pig. Invoice # c # i /7 ) Z g- fz 5/ Received By: <br />3 <br />TY <br />NT <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003 107b, 6-0 PRO q)-16-41-.