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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />Fast Food Restaurant <br />PHONE # Em' <br />In -N -Out Burger <br />626 813 8275 <br />HOME or MAILING ADDRESS <br />OWNER i OPERATOR <br />FAX# <br />I <br />13502 Hamburger Lane <br />CHECK If BILLING ADDRESS <br />I n -N -Out Burgers, a California Corporation <br />CITY Baldwin Park <br />STATE CA Zip 91706 <br />f.r�-�sC <br />FACILITY NAME <br />DATE: <br />ASSIGNED TO: <br />�A S <br />In -N -Out Burger <br />DATE: ((f �'Z,t;+ •-� (j <br />Date Service Completed (If already completed): <br />SERVICE CODE: S Z'Tj <br />SITE ADDRESS <br />P 1 E: / j�. C, <br />I <br />Golden Valley Parkway <br />Amount Paid 4 S <br />Lathrop <br />95330 <br />16514 StmetNumb.r <br />Direction <br />Ch k #�Jr <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />13052 Street Number <br />Hamburger Lane Street Name <br />CITY <br />STATE <br />ZIP <br />Baldwin Park <br />CA <br />91706 <br />PHONE#1 E'rT <br />APN# <br />LAND USE APPLICATION III <br />(626 1 8138275 <br />Portion of 191-190-64 <br />TBD <br />PHONE #2 En. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />In -N -Out Burgers, a California Corporation <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Em' <br />In -N -Out Burger <br />626 813 8275 <br />HOME or MAILING ADDRESS <br />FAX# <br />I <br />13502 Hamburger Lane <br />( ) <br />CITY Baldwin Park <br />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 forth. <br />I also certify that I have prepared this application and that the YBrk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL I s. <br />APPLICANT'S SIGNATURE: DATE: 10/25/18 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANA OTHER AUTHORIZED AGENT® Development Manager <br />IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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. Aa <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />` .,, <br />�;.PC l� V • Y V C 6,-5- Ci I^N Nt.EF'rY <br />0611 ,�F <br />y�s <br />/Ra <br />y0P <br />ggFY A�7V <br />ACCEPTED BY:u <br />f.r�-�sC <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />�A S <br />EMPLOYEE #: <br />DATE: ((f �'Z,t;+ •-� (j <br />Date Service Completed (If already completed): <br />SERVICE CODE: S Z'Tj <br />P 1 E: / j�. C, <br />Fee Amount: <br />Amount Paid 4 S <br />Payment Date <br />Payment Type <br />�_. <br />Invoice # <br />Ch k #�Jr <br />I Received By: <br />EHD 48-02-025 1SIR FORM (Golden Rod) <br />REVISED 11/17/2003 �✓ \0-) C `6 <br />