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RECLIVEU <br /> 0o'T Z 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIR E� TH SERVICE REQUEST <br /> OUROW-Sor Property FACILITY ID# SERVICE REQUEST# <br /> Temporary Retail Candy Store S ROO �6M <br /> OWNER/OPERATOR <br /> See's Candles Inc. CHECK If BILLING ADDRESS <br /> FAILI N ME <br /> Me s handles#302 <br /> SITE ADDRESS West Kettleman Lane Lodi 95242 <br /> 2414 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 210 El Camino Real <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S.San Francisco CA 94080 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 310 ) 287-4606 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> °55 901-7337 II II I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Pati Villanueva CHECK If BILLING ADDRESS13 <br /> BUSINESS NAME PHONE# EXT. <br /> See's Candies Inc. 866 901-7337 <br /> HOME or MAILING ADDRESS FAX# <br /> 210 El Camino Real ( 310 ) 842-4436 <br /> CITY S.San Francisco STATE CA Zip 94080 <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 /> 1 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 ST E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: VV ' `V' I \ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT® Maintenance Manager <br /> ffAPPL/CANT 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 environmental/site 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. � A <br /> TYPE OF SERVICE REQUESTED: Eb 6d n&UttX'}`D F <br /> COMMENTS: FOr/ O <br /> 104Q op <br /> TyFp�1NP , n' <br /> M <br /> ACCEPTED BY: & h EMPLOYEE#: DATE: 13 —) <br /> ASSIGNED TO: Q D ro EMPLOYEE#: DATE: Vb 31-I <br /> Date Service Completed (if already Completed): l SERVICE CODE: P/E: (602, <br /> Fee Amount: 152 Amount Pai /5;1.6D Payment Date 16124 -7 <br /> Payment Type Invoice# Check# /ZZ7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />