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Type of Business or Property SERVICE REQUEST# <br />EN INDIA GRAB & GO <br />Street Number <br />95336 <br />Ext.APN # <br />Ext.BOS District Location Code <br />) <br />zip93454 <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />6-5-24Vidal Pedraza Employee#: 6213 Date:Accepted By: <br />6-5-24Employee#: 8788 Date:Assigned to: <br />523 1601Service Code: <br />Payment DateFee Amount: <br />Invoice # <br />Payment 182567662 SR FORM (Golden Rod) <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, ST ATE and FEDERAL laws. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Comments: <br />Requesting plan review for the Indian Restaurant Grab & Go. <br />Manteca <br />________City <br />Yosemite <br />______________Street Name <br />E <br />Direction <br />95336 <br />Zip Code <br />Phone #2 <br />() <br />Gehane Fahmy <br />Date Service Completed (if already completed): <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />S. Austin RD <br />___________________Street Name <br />Zip <br />Requestor <br />Pawitar Singh_____ <br />Business Name <br />Atom Architects <br />Home or Mailing Address <br />709 E. Orange St <br />city Santa Maria <br />Indian Restaurant___________ <br />Owner / Operator <br />Sam’s Kitchen - ANIL MAN HAS <br />Facility Name <br />_______SAM’S KITCH <br />Site Address <br />Phone# <br />( 209)244-5207 <br />Fax# <br />____L_ <br />State CA <br />1385 <br />Street Number <br />Home or Mailing Address (If Different from Site Address) <br />285_________ <br />City <br />Manteca_____ <br />Phone #1 <br />( 727-)643-6607 <br />486 <br />Payment Type ^/U^rT <br />P/E: <br />VW <br />Received By: <br />Amount Paid <br />Check# <br />Check if Billing Address O <br />Check if Billing Address L4J <br />ext. y <br />_______________________ Date: 05-29-2024 <br />Property / Business OwnerD ^Operator / Manager Ot her Authorized Agent PM <br />If APPLICANT is not the BILLING Party, proof of authorization to sign is required Title <br />AUT HORIZATION 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 />----------------------------------1 <br />SJUH°7^ <br />CONTRACTOR / SERVICE REQUESTOR <br />Kh usfw 7^$ <br />Bl LU NG 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 />State <br />_____CA <br />Land Use Application #