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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PEx . <br />N�� 832-8898 <br />SERVICE REQUEST # <br />Restaurant <br />C" Elk Grove STATE CA zIP 95624 <br />SR ool2-+o i <br />OWNER / OPERATOR <br />HOA TCHANG <br />CHECK if BILLING ADORESSO <br />FACILITY NAME Ramen 101 <br />SITE ADDRESS <br />866 <br />�/�� <br />/�} j� <br />Benjamin Fjptj )a <br />StQ ton <br />Street Number <br />DIrA'dlen <br />zP5Z07 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Sheet Name <br />CITY <br />STATE zip <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />(916) 799-1288 <br />PHONE #2 Esr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Chris Chen CHECK if BILLING ADDRESS <br />BUSINESS NAM <br />EChris Construction Inc <br />PEx . <br />N�� 832-8898 <br />HOME or MAILING ADDRESS <br />8425 Tragus Way( <br />FAX# <br />) <br />C" Elk Grove STATE CA zIP 95624 <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to roe 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 <br />� and <br />dFFETDDE-R.AAL laws. <br />\ <br />APPLICANT'S SIGNATURE: ` - I DATE: 10/5/2020 <br />PROPERTY /BUSDVEss OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® TW Designers <br />IfAPPL1CANT 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 environment /site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at / + Yiple it is <br />provided to me or my representative. RE('`C„ N7' <br />TYPE OF SERVICE REQUESTED: "FIAvI, <br />COMMENTS: <br />U b 7020 <br />SAN VDAQUI <br />HEACTHDE ARTMF�ry <br />ACCEPTED BY: -'r, EMPLOYEE M DATE: <br />ASSIGNED TO: % EMPLOYEE M DATE: v �( <br />Date Service Completed (if already completed): SERMCE CODE: Z S P I E. I00 <br />Fee Amount: 1 Li CSS Amount Pa' L44!a /l-/) IPayment Date <br />Payment Type ('i I Invoice # II Check # / . -� 88 -7 I Received By: /'�� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />