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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Boba Tea Shop 2 b-)9S 5 3 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRES <br /> Manuel Keo & Asia Oun S <br /> FACILITY NAME <br /> Sweet Lab <br /> SITE ADDRESS 1401 $ Lower Sacramento, Suite 130 Lodi 95242 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 861 Nutmeg Landing Lane <br /> Street Number Street Name <br /> CITY Manteca STATE CA Zip 95336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 629-8672 058-030-240 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> Stacey Wellnitz <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 616 14th Street ( ) <br /> CITY Modesto STATE CA Zip 95354 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONNIFNTAL HFALTH Dr•.PARTNIFNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 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 I ws. <br /> APPLICANT'S SIGNATURE: DATE: ZZ 1e <br /> PROPERTY/BUSINESS OWNER❑ OPR.RATOR/NI>NA(;ER ❑ Ol'IIF.R Alll'IIORIZEi)AGr?N'1'�L- ROEC-r MA/<tifA&eK <br /> IfAPPt.tCANT is not the B/LLIA-G PARrr,proof of aulhoriZalion 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 arid 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 yW�( [inle it is <br /> provided to me or my representative. r Y/M <br /> TYPE OF SERVICE REQUESTED: EI►/ <br /> COMMENTS: AUG <br /> sgjo ?2 2018 <br /> if 7}i pEPgRNT'gL <br /> TMENT <br /> ACCEPTED BY: EMPLOYEE#: 013 DATE: ZZ <br /> ASSIGNED TO: EMPLOYEE#: l Q DATE: Q� J / <br /> Date Service Compl ted (if already completed): SERVICE CODE: rJ,3 PIE: G <br /> Fee Amount: Amount Pai �.0D Payment Date 8�7 d <br /> Payment Type Invoice# Che # �� 7d� Receive6 By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �""' ' ""—' U V � �-� <br /> � <br />