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FACILITY ID U <br />DEZHI HUANG <br />Facuitt Name <br />RIETI LN <br />City State <br />Ext. <br />Email Location CodeExt. <br />TEDDH86@GMAIL.COM <br />Requestor <br />Business Name Ext. <br />7303131 <br />iperator I Manager <br />Employee #:Accepted By: <br />Employee#:Assigned to: <br />Fee Amount: <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />SERVICE REQUEST# <br />SkajoenGZl- <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />Type of Business or Property <br />AICE.TEA LLC (FOOD FACILITY) <br />Owner I Operator <br />LODI <br />City <br />TURNER RDSTE275 <br />_____________Street Name <br />9045 <br />______Street Number <br />95242 <br />Zip Code <br />w <br />Direction <br /> D ATE: <br />Other Authorized Agent <br />A.ICE <br />Site Address 2401 <br />_________________Street Number__________________________ <br />Home or Mailing Address (if Different from site Address) <br />Type of Service Requested: <br />Comments: <br />RH Painting and Remodeling Inc <br />Home or Maiung Address <br />CONTRACTOR / SERVICE REQUESTOR <br />ROMON NAVARRETE <br />Z <st vVla c o <br />Date Service Completed (If already completed): <br />Land Use Application # <br />APPROXIMATELY 800 S.F. <br />BOS District <br />Amount Pai <br />Check # <br />Phone # <br />(209) <br />Fax# <br />j__L <br />email rhpainting88@icloud.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 />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'Iaws. <br />APPLICANT’S SIGNATURE: <br />STOCKTON <br />Phone #1 <br />(209) 6237928 <br />Phone #2 <br />() <br />Service Code: <br />Payment Date <br />| Received By: <br />Check if Billing Address!^ <br />Check if Rnting AddrfscJ^ <br />Payment Type <br />ClTY STOCKTON Z|P 95205 <br />APN# <br />01530006 <br />Property / Business Owner E <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 provided to me or my <br />represen,a,ive' —payment <br />—^ECE/ved— <br />JAN 1 7 2024 <br />Date: | <br />D>TE: I—l~7-Z4 <br />,.. I PI,E: 160 / <br />'eceived By: fjtrf) <br />2048 E Church St <br />STATE CA <br />Street Name___________ <br />CA Z,P 95212