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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RESTAURANT (RETAILSEID) q 3q SYz008 �2 <br /> OWNER/OPERATOR <br /> LISA LEE CHECK If BILLING ADDRESS <br /> FACILITY NAME LEE'S CHINESSE RESTAURANT <br /> SITE ADDRESS 102 PIERCE AVE MANTECA 95336 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME AS ABOVEStreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( ) 209 4 001 9464 <br /> PHONE#2 209 4H2 9859 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR LISA LEE CHECKIf BILLING ADDRESS <br /> BUSINESS NAME LEE'S CHINESSE RESTAURANT PHONE# Err. <br /> HOME or MAILING ADDRESS 732 TAHOE ST Fax# <br /> ( ) <br /> CITY MANTECA STATE CA ZIP 95337 <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 d FEDERAL l <br /> APPLICANT'S SIGNATURE: �ft-.Q� DATE: 06/21/2021 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLLCANT is not the BILL/NG 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 environmentallsite 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 /> TYPE OF SERVICE REQUESTED: AY <br /> COMMENTS: <br /> E/VED <br /> JUN 2 21021 <br /> &%JQgQUI <br /> ��o°�MEiyloU'�r <br /> ACCEPTED BY: nl't�DEMPLOYEE#: DATE: <br /> ASSIGNEDTO: en _ rV'1L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Du'I, P IE: Uj,o <br /> Fee Amount: \,S2 Amount Paid 5a o Payment Date : 2 2f <br /> Payment Type Invoice# -QWC—" C)q Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 C <br /> pyo lloLIS Z J <br />