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San Joaquin County Environmental Health Department <br />Owner / Operator <br />Vishal Nayyar <br />Facility Name The Hangar - MHT <br />Site Address <br />41 S ESTADOS ST <br />Street Number <br />City MOUNTAIN HOUSE 95391 <br />Ext.APN #Land Use Application # <br />25455034(408) 204-9478 <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />TBD <br />Ext.Business Name <br />Home or Mailing Address <br />) <br />City State Zip <br />02/16/2024APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Employee#:Date:Accepted By: <br />Employee#:Assigned to: <br />Service Code: <br />Payment DateFee Amount: <br />Check #Invoice # <br />SR FORM (Golden Rod) <br />BILLINC; 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 />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Type of Business or Property <br />Restaurant <br />mountain house, ca <br />City <br />Phone#2 <br />( ) <br />Phone#1 <br />( ) <br />SERVICE REQUEST# <br />SfeffiCDSTT-BH <br />95391 <br />Zip Code <br />19689S <br />Street Number <br />MOUNTAIN HOUSE PARKWAY <br />Street Name <br />SERVICE REQUEST <br />FACILITY ID # <br />v- -i, <br />I---<V-t <br />Date Service Completed (if already completed): <br />Direction_________________ <br />Home or MAILING Address (If Different from Site Address) <br />Street Name <br />Zip <br />______________ <br />Payment Type <br />Check if Billing Address O <br />Check if Billing Address <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 andyrEDERAL laws. <br />‘___________________________ Date: <br />Property / Business OwnerD Operator/ Manager S O i her Authorized Agent Project Coordinator <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 <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 same time it is <br />provided to me or my representative. ' /1/7* <br />^05 J <br />^Njoa <br />Phone# <br />J___I <br />Fax# <br />( <br />State <br />ca <br />^ 4 -^4 <br />DATE: -Z4 <br />Received By: /Jrh <br />Amount Pai <br />I