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l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 0 SERVICE REQUEST i <br /> Coffee Shop AUt7740 00 _W7S <br /> OWNER i OPERATOR <br /> Samantha Oliver acrc"g""r•'""=0 <br /> FAc&rrY NAME <br /> House of Coffees <br /> 242 <br /> SITE ADDRESS Lakewood Mall Lodi 95 <br /> 239 Inn Number <br /> HOME or MAILING ADDRESS (if Different from Site Addreaa) <br /> CITY \ STATE \\ \\ ZIP <br /> PHONE IH En. APN A LAND USE APPLICATION N <br /> (209 ) 712-2864 Q yoo <br /> PHONE A2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 209) 368-2611 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CNECR N OLLM ADDRESS <br /> Samantha Oliver <br /> BUSINESS NAME PHONE III Ez*. <br /> House of Coffees 209 712-2864 <br /> HOME or MAIuNG ADDRESS FAx III <br /> 239 Lakewood Mall ( 1 <br /> CITY Lodi STATE Ca 25P 95242 <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 ENviRoNMENfAL 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,Standar T laws. <br /> APPLICANT'S SIGNATURE: DATE: OZ 12 1 �2a 1fl <br /> PROPERTY/Bumam OWNER® OPERATOR I MANAGER OTHER ADTAORizED AGENT❑ <br /> IjAPP6ICANT is not the Bat/NG PARTY proof ojaarhorizalion to sign is required rule <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 and all results, geotechnical data and/or environmentaVoG,4"wl <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t� <br /> provided to me or my representative. SCA <br /> TYPE OF SERVICE REQUESTED: Q `a <br /> COMMENTS: / B JOgQoN CID <br /> 8 <br /> Nr <br /> ACCEPTED BY: EMPLOYEE M DATE: a.a,3 -/IJ CJ <br /> ASSIGNED TO: 71 <br /> L M)111- EMPLOYEE i{: DATE:OA a•a -�d <br /> Date Service Completed (If aimay completed): SERVICECODE: PIE <br /> Fee Amount: Amount Pal /SD� Payment Date <br /> Payment Type Invoice# C S 7,� q7 R� By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />