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Site Address <br />Direction <br />City StateDublin 94568 <br />Ext.APN # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />) <br />State ZipCityElk Grove 95624 <br />Type of Service Requested: <br />Comments: <br />Date:Employee #:Accepted By: <br />Date:Employee #:Assigned to: <br />Fee Amount: <br />Invoice #Payment Type <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />SERVICE REQUEST# <br />SfcGXD -2.2. <br />A 95219 <br />Zip Code <br />Type of Business or Property <br />Restaurant <br />Owner I Operator <br />______Benny Lin <br />Facility Name <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY id # <br />10710 <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Ca <br />Land Use Application # <br />Stockton <br />________________City____________ <br />element way <br />Street Name <br />Zip <br />Bao Bao Restaurant________________ <br />Trinity Pkwy Ste C <br />___________________Street Name_____ <br />3440 <br />Street Number <br />Check if Billing Address <br />Phone #1 <br />(510)239-6480 <br />Phone #2 <br />( ) <br />________ Chirs Chen <br />Business Name <br />Check if Billing Address O <br />- <br />l//5^ <br />Service Code: S <br />Payment Date -’//Z) y.T) <br />Received By: /// ' <br />jc’ • TL? <br />P/E: <br />Phone# <br />J___L <br />Fax# <br />J__ <br />Ca <br />Ext. <br />916 832 8898 <br />co <br />Date Service Completed (if already completed): <br />Amount Paic// <br />Check# <br />Chris Construction Inc <br />Home or Mailing Address 8425 Tragus Way <br />BILLING ACKNOWLEDGEMENT: L 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 />COUN TY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT’S SIGNATURE: DATE: May 08, 2023 <br />Property/ Business Owner Operator / Manager Other Authorized Agent ESI 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, 1, 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 Healt h Depart ment as soon as it is available and at the same time it is <br />provided to me or my representative. <br />102023 <br />RTM£Nr