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San Joaquin County Environmental Health Department <br />Check if Billing Address <br />Facility Name Staybridge Suites <br />95337 <br />street Name : Danniel's StreetDirection <br />Zip Code <br />Street Name <br />9950 Koa Lane <br />Street Number <br />City Elk Grove,95624State ca Zip <br />Ext.Land Use Application #APN# 222-250-17 <br />Ext.BOS District Location Code <br />Ext.BUSINESS Name : Ace Design & Construction <br />Home or Mailing ADDRESS : 1024 Iron Point Road, Street No. 1046 <br />CITY: Folsom, CA State <br />APPLICANT’S SIGNATURE:Date: 10-17-2022Off <br />electronic Confirmation payment 151343657 <br />Vidal PedrazaAccepted By:Employee#: 6213 Date:10-18-22 <br />10-18-22Assigned to:Date:8788 <br />Service Code:523 1601 <br />Fee Amount:Payment Date <br />/S73^3G5 7 <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 />Type of Business or Property Business <br />Commercial <br />Owner/Operator Avtar <br />Dhillon <br />Manteca, CA <br />City <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 />SERVICE REQUEST # <br />Employee#: ___________ <br />________________ 468 <br />Payment Type ^5^ <br />Type of Service Requested: Health department review <br />Comments: <br />Phone #1 <br />( 916-952-6552 ) <br />Phone #2 <br />( ) <br />Phone # <br />( 702-786-0771 ) <br />Fax# <br />( 702-714-1237 ) <br />ZIP 95630 <br />SERVICE REQUEST <br />FACILITY ID # <br />Check if Billing Address O <br />______________CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR: Jaspal Singh Sidhu <br />P/E: <br />Received By: ' <br />Property / Business Ow.nerD/ Operator / Manager Other Authorized Agent <br />If APPLICANT is not the Hilling 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, 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 tl^saine time it is <br />provided to me or my representative. O A / <br />UCT 18 202? <br />SANJOj, <br />Site Address Staybridge Suites, <br />1878 Danniel's Street, San Joaquin <br />County, Manteca, CA <br />____________________Street Number <br />Home or Mailing Address (If Different from Site Address) <br />Gehane Fahmy <br />Date Service Completed (if already completed): <br />I Amount Paid <br />Invoice # Check #