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San Joaquin County Environmental Health Department <br />Type of Business or Property <br />Restaurant <br />Ext. <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Ext. <br />) <br />Zip 97214Portland <br />APPLICANT’S SIGNATURE:06.14.24 <br />Type of Service Requested: <br />Comments: <br />Plan check <br />Date:Employee #:Accepted By:Vidal Pedraza <br />Assigned to: <br />1601523 <br />Fee Amount: <br />Invoice # <br />SR FORM (Golden Rod) <br />Payment 183799581 <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 />Gehane Fahmy_________ <br />Date Service Completed (if already completed): <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />APN # <br />26830008 <br />Manteca <br />City <br />Phone#2 <br />() <br />Atherton Drive <br />Street Name <br />w <br />Direction <br />229 E <br />Street Number <br />95337 <br />Zip Code <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 />H Date: <br />Property / Business OwnerO Operator / Manager Ot her Authorized Agent El <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 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 />City <br />Lathrop________ <br />Phone #1 <br />( 510 ) 329-4806 <br />Requestor <br />Dustin Henion_______________ <br />Business Name <br />Gnich Architecture Studio_____ <br />Home or Mailing ADDRESS <br />1001 SE Sandy Blvd, Suite 100 <br />City <br />SERVICE REQUEST <br />FACILITY ID # <br />Phone# <br />( 971 ) 346-2526 <br />Fax# <br />( <br />8788 <br />Service Code: <br />Louise Ave <br />__________________Street Name_____ <br />State Zip <br />CA_____________95330 <br />Land Use Application # <br />7/1/24 <br />P/E: <br />Payment Date 7//G^ <br />Received By: <br />Project Manager <br />Title <br />_______________486 <br />Payment Type \J <br />Amount Pai^ <br />Check # <br />Check if Billing Address LU <br />SERVICE REQUEST# <br />AP34006>05 <br />Check if Billing Address LUOwner / Operator <br />Manteca MMP Inc., ATTN: Parminder Singh <br />Facility Name <br />Mountain Mike's Pizza <br />Site Address <br />2235 (Suite A) <br />______________________Street Number <br />Home or Mailing Address (If Different from Site Address) <br />Stateor <br />______ <br />7/1/24 <br />Date: <br />6213 <br />Employee #: