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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fast Food Restaurant <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS O <br /> In-N-Out Burgers,a California Corporation <br /> FACILITY NAME <br /> In-N-Out Burger <br /> SITE ADDRESS Golden Valley Parkway Lathrop 95330 <br /> 16514 Street Number I Direction I Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 13052 Street NumberHamburger Lane Street Name <br /> CITY STATE ZIP <br /> Baldwin Park CA 91706 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (626 ) 8138275 Portion of 191-190-64 TBD <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR In-N-Out Burgers,a California Corporation CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# ExT. <br /> In-N-Out Burger 626 8138275 <br /> HOME or MAILING ADDRESS FAx# <br /> 13502 Hamburger Lane ( ) <br /> CITY Baldwin Park STATE CA ZIP 91706 <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 rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL 1 S. <br /> APPLICANT'S SIGNATURE: DATE: 10/25/18 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANA OTHER AUTHORIZED AGENT® Development Manager <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />