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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# RESTAURANT �� Z j o S(L 03`g-SLAB o OWNER I OPERATOR // j J (,� CHECK if BILLING ADDRESS FACILITY NAME PUNJABI INDIAN MARKET SITE ADDRESS 1031 I I S. MAIN ST I MANTECA I 95337 Street Number I Direction I Street Name I city I Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 En. APN# LAND USE APPLICATION# PHONE#2 '9012- Em BOS DISTRICT LOCATION CODE c ) b65 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME (TBD` PHONE# EX. 1 ( HOME Or MAILING ADDRESS FAx# ( I CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards, STATE an I'e.DERAL laws. APPLICANT'S SIGNATURE: DATE: 12/18/2020 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ISI HUAN VU, PE If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. P TYPE OF SERVICE REQUESTED: Plan review for permit FC Nr COMMENTS: O Remodel an existing storage space of a market into a commercial kitchen. s MqR 3 p Restroom, HVAC distribution system and general lighting are existing. h V/VOQQ(I/ Z�ZI Not( M (P) - DtAv ' FACry�FPgR MFNTY ACCEPTED BY: <f4 v-.-.A 25; c L EMPLOYEE M DATE: 2-1—Zf ASSIGNEDTO: (,� fA.l EMPLOYEE DATE: 3J—'zx� 'Z'I Date Service Completed (if already completed): SERVICE CODE: PIE: PIE: 6 Fee Amount: -1J Amount Pal7C,YO Payment Date c3 Payment Type �� Invoice# fCheck# �Z�S� Receiv d By: EHD 46-02-025 C Z '�'`j 1-1/6SR FORM(Golden Rod) _ REVISED 11/17/2003