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San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID #SERVICE REQUEST# <br />Commercial Restaurant <br />Check if Billing Address' <br />Facility Name <br />Site Address S Mountain House 95391 <br />Direction City Zip Code <br />City StateMountain House CA 95391 <br />Ext.Land Use Application # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />John Ha <br />Ext.Business Name Innovative Design Architecture Inc. <br />Home or Mailing Address 510 Lawrence Expwy. Suite 201 ) <br />City State ZipSunnyvaleCA 94085 <br />APPLICANT’S SIGNATURE: 06-12-2023 <br />Architect <br />Title <br />Type of Service Requested: <br />Comments: <br />Date: <br />Date: <br />Fee Amount: <br />Payment Type <br />SR FORM (Golden Rod) <br />MS’ <br />Phone#2 <br />( ) <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 aud^DERAL laws. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Phone#1 <br />( 510 ) 825-1911 <br />Mountain house Pkwy. <br />Street Name <br />361 <br />Street Number <br />E Parkco Ave. <br />Street Name <br />Zip <br />19693 <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Phone# <br />________________________( 408 )245-0711 <br />Fax# <br /> ( <br />Owner I Operator Jams-hta Ahmad <br />Fremont Kabob <br />Amount Paid <br />Check # <br />Check if Billing Address <br />7,7 J <br />UoOl <br />72443 " , <br />Received By: <br />4 — <br />Invoice # <br />1(0^1^15 <br />Employee#: <br />Employee#: 4 5^1 <br />Service Code: 5^3 <br />Payment Date <br />Date: <br />Property/ Business OwnerD Operator / Manager □ Other Authorized Agent^ <br />If Applicant is not the Billing Party, proof of authorization to sign is required <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 cnvironmental/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. O-. <br />^1^242^ <br />APN # <br />254-55-026 <br />Accepted By: ________ <br />Assigned to: <br />Date Service Completed (if already completed):